Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------•----------- _ ��� .. <br /> (Complete in Triplicate) <br /> Permit No. <br /> - -------------- ------------------ <br /> .---__--- This Permit Expires 1 Year From Date Issued 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 <br /> with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSlL'OCATION-4"�Z �-_C�' <br /> ' CENSUS TRACT --------------- <br /> --------- - - <br /> Owner's Name - r hone" "� 5 �. <br /> -?`f a �� <br /> Address r�T��- City <br /> Contractor's Name ------- ---- -- - --- jre�ez� <br /> -Q /( --------------License # ---- Phone <br /> Installation will serve:` ResidenceXA a-Whent"House[ICommercial:❑Trailer Court ❑ <br /> M <br /> E <br /> Motel:❑Other ------------ ; <br /> I <br /> Number of living units:.-- Numberof ms _-_-#_Garbage inderc.�___ Lot Size -IQ_ I- <br /> ------ <br /> Water Supply: Public System and naOr me __---__----__ _ __Private ❑ <br /> --- -------- -----------•--- <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy-Loam ❑ Clay Loam,l] <br /> # Hardpan E] Adobe ` Fill Material ------. - <br /> "'If yes, type -___--_-__-__ <br /> ------------ <br /> J <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 /> PACKAGE TREATMENT [ ] ;SEPTIC TANK[ J -._Size------------------------------------------------ Liquid Depth -----------•------------_- : <br /> Capacity ---- --------------- Type -------------------- Material---------------------- No. Compartments ------------ •--- W <br /> Distance to nearest: Well -------------------------- Foundation --_-------------____-- Prop. Line ----------.----•-•_-__-, <br /> LEACHING LINE [ j No.tof Lines ---- ------------------- Length of each line---------------------------- Total Length .---_--.._-•___........... <br /> t 'D' Box .--______- Type Filter Material --------------------Depth Filter Material ------------------------------ ............ <br /> Distance.to nearest: Well -.-____-___-----_ ---- Foundation ------------------- Property Line <br /> t --------------•---•----- <br /> SEEPAGE PIT Depth' -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 1 <br /> • Wate Table Depth ---------------------------------------=--- ----Rock Size ---- { <br /> Dista nce+to nearest: Well ----------------------------------------Foundation <br /> --------------- ---- Prop. Line -------------- ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------_--------------------) <br /> Septic Tank (Specify Requirements) --------- * ----- - ---- <br /> - �L <br /> --------••--------- <br /> Disposal Field (Specify Requirements) - .;� _f_- --_ <br /> ---------------------- ►., -- <br /> n <br /> - ----------------------------------------------------- <br /> --------------------------t.---------------- i r :-. <br /> red <br /> I hereby certify thI t I have prepared(Draw <br /> s application and Ithaca h - <br /> ----------- - ---- ------ <br /> dition on reverse side) <br /> e work wil be done in accordance with San Joaquin <br /> County Ordinances, State Laws,Eand Rules and Regulations of the San Joaquin"Local Health District. Home owner or licen- <br /> sed agents signature certifies thefollowing: f <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 bec e*b*ick o rk 's Compens laws of CaliforniaSigned .-- ------.-_ - -------------- _-OwnerA <br /> BY ------ ------------------------------------- Title ---------------- ; <br /> ` ------------------------ ------------------------ <br /> t (If other than owner) <br /> f I <br /> a F R .DEPARTMENT USE./ONLY ' <br /> APPLICATION ACCEPTED BY --- _`�• � E <br /> ------------------------ --------- DAT <br /> BUILDING PERMIT` ISSUED + � .- , 4 <br /> --------------------------------- ------------ ----------------- <br /> ADDITIONAL COMMENTS /- I I - - �. ° .. E 1 <br /> i F ; `v ..-- ------------- ----------------------------------------------- <br /> ------------------------- <br /> ----- -------------------- # I <br /> f - ------------------------------------------ <br /> -- --- ----------- <br /> ------- --- <br /> -------------- - ----------------------------------------------- <br /> ----- ------- <br /> Fina Inspection bY.:. Date. <br /> -------------- - <br /> SAN JO QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M, <br />