Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------- --- --- ---------------------- ----------- Permit <br /> M _ (Complete in Triplicate) <br /> ----- r <br /> Date Issued <br /> ------- ` `� This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> - CENSUS TRACT - ----- <br /> JOB ADDRESS/LOCATION .---- ------ - �''- � ® <br /> ,1" � -Phone t �f <br /> Owner's Name //� '�IJI --------------------------------------------- ---------- --------- <br /> Address .- ' ',: ----------------------- �� ------------------------------------------- <br /> 6 <br /> ------------- ------- -� 4 <br /> / L'fy ��f� -,��- <br /> icense ---�--- { <br /> Contractor's Name F- ���1 <br /> installation will serve: Residence Rf Apartment House ❑ Commercial :❑Trailer Court ;❑ <br /> j Motel El Other -------------------------------------------- <br /> Number of living un+its:-A--------Number of bedrooms ----_-_--_Garbage Grinder ------------ Lot Size r '---------••-- <br /> Water Supply: Public-System and name ---------------------------------•--------------------------------------.- ------------------------------------Private`R <br /> Character of soil to a depth of'-3feet: Sand'(J Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe F-] Fill Material ------------ If yes, type -------------------_------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> -- Liquid Depth -------------- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------------___________-------- 9 P ---•-------• i <br /> Capacity -------------------- Type --------/th <br /> --- Mate al---------- ----------- o. Compartments ------ -----•-----•--- i <br /> Distance to nearest: Well --------- --------- -------Foundation - -------------------- Prop. Line --..---_-_-_-------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Lena line------------------ ---.-_--- Total Length ---------- _---.-.__.___. <br /> `D' Box ------------ Type Filter Mate -- -------------Depth F' er Material --------------------•--------.-------------- i <br /> Distance to nearest: Well ----------- Foundation ----------.-------- Property Line. --------.-_-----....-- <br /> SEEPAGE PIT [ 1 Depth -------------------- Diameter -- ---. Number ----- -----------_--------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ---------------------Distance to nearest: Well ------------- ---------------•--F undation -------------------- Prop. Line ----------.----------- . <br /> REPAIR./ADDITION(Prev. Sanitation Permit# --------------------------------- ---------- ate ----------------------------------11 Q <br /> SepticTank (Specify Requirements) ----------------------`-------------------------------------------------------------------------- ------ -------------------------------- <br /> Disposal Field (Specify Requirements) �> 1 ---- fes - fes'"---� '� <br /> n'd <br /> - I _ _ _ vii Qom- . K- ------------------------------------------------ <br /> ---------- _ _ <br /> --------- - ---- <br /> (Draw existing and required adclitiion on reverse side) - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - --- -- --------- --- ---------------- Owner <br /> BY ------------------- Title ------...------------ --------------------- --- ------------------ <br /> E (if other than own r) <br /> FOR DEPARTMENT USE ONLY J <br /> APPLICATION ACCEPTED BY -------- f r -t---------------------------- -----------------------------------------. DATE <br /> BUILDINGPERMIT ISSUED -------------------- -----------------------------------------:-------------------------------------------DATE ------ ------•----------------------------- <br /> ADDITIONAL COMMENTS - ----------------------------------- --------------------------------------------------- ----------- <br /> ------------------------------------------ <br /> ---------------------------------- --- <br /> - -- -------Q�K--------------_ '.------1 � y --------- ------- --------- ----------- <br /> -------------- ------------ ---- - " <br /> --- --- - ---- <br /> --- <br /> FinalInspection b : ----------- ------ ---- ----- -------------- --------------------------------Date ---- = - -` ------------ <br /> � � SA UIN LOCAL HEALTH DISTRICT <br /> G� <br /> E. H. 9 1-'68 Rev. 5M <br />