Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT , <br /> -------------- Permit No. <br /> (Complete in Triplicate) <br /> -------- =------------------------------------------- IS--75C <br /> Date Issued <br /> - <br /> -------------------------- This Permit Expires 1 Year From Date Issued i <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This a plication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . __ -_-_ ___ _ .___ _- ----------------- ---------- ----------------- --------CENSUS TRACT __________________________ <br /> Owner's Name .----��-------- '-----11:------------------------------- Phone <br /> �,Vr Address 6 - .- : *------------------------------------ City <br /> Contractor's Name .__Z11 ----------------------------------•-------------------------License # --------:-------------- Phone ------------------------------ <br /> Installation will serve: Residence *Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- r <br /> Number of living units:------ ___: Number of bedrooms ----------Garba_ge Grinder ------------ Lot Size _ l,Z --_______________________•- <br /> Water Supply: Public System and name -------------------------------------.------- ----------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay LoamZ <br /> - 4 Hardpan, Adobe-❑ Fill Material __._ ---- If yes, type ___________________--_____ <br /> (Plot plan, showing size of lotI 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 Size__ _D- -_ ---- ----- _______.-___ Liquid Depth __, ________________ <br /> Capacity AC-0-0 Type -- Material __ No. Compartments 2 _______________ <br /> ' _Foundation -fd-*__-----_____ Pro Line __,�___:__...._. <br /> Distance to nearest: Well __�__________________________ _ p. <br /> -13 ------------- ) J <br /> 1 <br /> 'D' Box._ _-a---- Type Filter Material _/ '_________Depth Filter Material ----f-9---''_____________________________ <br /> Distance to nearest: Well __ 6�_____________ Foundation ----/4.............. Property Line r-- V <br /> SEEPAGE PIT Depth _.2,1-- -------- Diameter _ _______ Number --------------- Rock Filled Yesj.K No C] <br /> i <br /> Water Table'DepthO-a,---------------------------------•Rock Size ---:[s�:_- --------- <br /> i <br /> Distance to nearest: Well __/��____________________________Foundation --- t�.____.____ Prop. Line J7_.__._________.. <br /> REPAIRfADD[TION{Prey. Sanitation Permit# -------------------------------------------- Date ----------------------------------)., <br /> 1 ----------�, <br /> Septic Tank [Specify Requirements) ----------- ------------------- -- ------------------------------- ---------------- ------------- -•�------------------ <br /> DisposalField (Specify Requirements) -----------------------------•------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------- ` ------------------------------------------------------ ------- ---------------- ------------------------------------------------- <br /> - ------------ --------------------------------------------- - -------- ----- <br /> I (Draw existing and required addition 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 0 <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 t* <br /> as to beco a su . ct to Workman's Compensation laws of California." <br /> Signed ----- f _ AA ------------ Owner R <br /> s --------------------------- Title ------------ ------------------------------------------- r <br /> BY ---------------------------} ------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- --------------------------•---------------------------------------, DATE ------------------- <br /> BUiLDING PERMIT ISSUED -------t- ----------f----=---------------------------------------- -------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS -__.___` --__ _ -________ <br /> ---- -------------------------- f7y---Ao-_-_A----------------------------------------------- <br /> ------------------------------------------1- - --------- ------------------------------------------ ---------------------------------------------------- <br /> - --- -------'-- ------------------ ---------------------------- ------------------ _ - <br /> - --------- - <br /> "" Final Inspection by: .___ <br /> --------------- <br /> °= • - -_ _- - - -------------------- •---------------- -------------------------------.Date ------- --��---�-�-- -- - --------- <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />