Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT e�r� <br /> (Complete in Triplicate) <br /> Permit No. <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 with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - -c ----4`-r----'11- -------------------CENSUS TRACT -------------------------- <br /> Owner's Name ---------------------------------------------- -------------------- -------Phone ------ --------------------•---- <br /> Address -----------755 ( Ci <br /> Contractor's Name t _ - <br /> Y <br /> ----- -- - - - ------- <br /> - `r- License # -f e 3c 1----- Phone ------------------------------ <br /> Installation will serve: Residence [!!J Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other ---- ---- - ----------------------------- <br /> Number of living units------- Number of bedrooms _--3-----Garbage Grinder ------------ Lot Size ..-- „�-.---...- <br /> Water Supply: Public System and,name ---------------------------------••--------- ---------------------------------•--------------------------------Private [`f <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Z Clay Loam ❑ <br /> I Hardpan ❑ Adobe ❑ 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK'f J Size------------------------------------------------ Liquid Depth ----.-------------_----_-_ <br /> Capacity -------------------- Type -------------------- Material------------ --------- No. Compartments ----------.......... (� <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------.._..... 1 <br /> LEACHING LINE [ ] No. of Lines .-------_-------------- Length of each line- ------------------- Total Length -.------_----_---__--_-...-_ <br /> 'D' Box -.----.----- Type Filter Material --------------------Depth Filter Material --------------------.---_---__--_---_---_-._ <br /> Distance to nearest: Well ------------------------ Foundation ------------..---------- Property Line ---_--_-_-.._.-._....... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------------------ Rock Filled Yes j] No C1 <br /> Water Table Depth ------------------------------------------------Rock Size -----------------------•---•---- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -..-------..--_-.--__. , <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------- ----------- Date ---__--------._-.--------_-_---_-) <br /> SepticTank (Specify Requirements) ---------- -------------------c-------------------,---------------------------------•-------------- ------------•.,----------------------•---- <br /> Disposal Field Specify Requirements) -q_t�.0 -._/e7__.. - - .,_ <br /> V <br /> �C- '_ _ <br /> {Q ''�- -- - - --- ------------------------ <br /> ------------------ -------- ------------ ---------------------------- - - ----------------------------------------------------- ------ ----- -- <br /> (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 <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 /> - - - -- - ------ <br /> BY --------------------------- <br /> /1iYu.d.[ Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- - -.- ---- ----------------------- DATE ---?�- -7- <br /> BUILDING PERMIT ISSUED -------- - DATE ------------------------------------------- <br /> ADDITIONAL COMME=NTS .--------- <br /> ------------------------- <br /> ..---------------------------- - ------ ---------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------ ---------------------------------------------------------------------------- <br /> -------- ------------------------- - - ------------- _ <br /> i <br /> 71, <br /> Final Inspection by: -- / ----------------------- --------•------- ------------------------------Date ---- <br /> - <br /> -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />