Laserfiche WebLink
: e <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> t <br /> ...-...... Permit No. ..7`_ �Q d <br />` IComplete in Triplicate) <br /> ...._................................................... This Permit Expires 1 Year From Date Issued <br /> Date issued <br /> l <br /> Application is hereby made to the San Joaquin Local Health District .for a permit to constructsand install the work herein <br /> described. This application is made in compliance with aunty Ordinance No. 544 and existing Rules anal Regulations: <br /> JOB ADDRESS/LOCAT N,.4:�� -7 a.; ...�... .. .--•' CENSUS TRACT...................... <br /> Owner's Name . � �� M.. ... _ Phone 1 <br /> g` S <br /> Ct �ae-t .1. .� ' <br /> s <br /> -one:..Contractor's Name .: - Licnse #Address. o _ o :..... <br /> Installation will serve: r Residence [ Apartment Houseln-Camrrercial-OTrailerCourt <br /> Motel.00th <br /> g ,units .,. .. ;. Number of. bedrooms_.:..•_ <br /> Number of livin Ga rbage,,.Grinder .... Lot Size _...__._.............. <br /> --------- ....... <br /> Water Supply:. Public System and name .... ..._....... :_.. rivate Q <br /> .:. <br /> P <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay E] Peat sandy Loam; ay Loam <br /> Hardpan 0 Adobe Fill Material . If'yes,type .-. _ _. _ .. <br /> -i --. - - <br /> (Plot plan,, showing size'of (ot, .locotion ,of,.systern in relation to.*ells,.'buildirigs, etc ..mutt be. placed; on .reverse',side. <br /> NEW]INSTALLATION: IN,a se tic".tank or 'see 'a e, it Oermitted if ` ybIic sewer is civoilabl :witkin 200 feet,): <br /> PACKAGEiTREATMENT [ ] SEPTIC TANK} ] Size Liquid Depth <br /> d ---,.: . ., -. �. <br /> i Capacity .... TYPe Material No.- Compartments .....:...... ......::. <br /> ce to nearest: Well `.. ... . ... ... .! '- :_ _Foundation Prop `Line-_ <br /> i Di'stan t <br /> LEACHING LINE [ } No. of Lines . ' _- Length oUeach line. . ' ..._ Total; terigth <br /> i <br /> 'DI-96i '::'.;.. " -Type"Filter:IdMateeial Depth`Filter"Material ' <br /> Distance to nearest:-Well Foundation .` i . Property Line _' ._ : '....... .. <br /> r - <br /> S EPS AGE PIT .[ ! - .Depth r -' Diameter Numkier, ' - Rock Filled Yes No <br /> -- ❑. <br /> Water T <br /> ab a De th, Rock Size. <br /> : <br /> r <br /> : , - <br /> Disance to.nea'rest:;Well a oundation Prop Line _ ...... <br /> R9PAIR ADDITION <br /> � <br /> (Prev; . Sanitation Permit# ....... :,Date _ -. - ._ <br /> r ' <br /> Septic Tank (Specify'Requirements) <br /> --- - <br /> osal Field (specify Requirements) <br /> this <br /> P <br /> .. ..... ... ....... ..... " ' <br /> (Drdw 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 accordancewith, San Joaquin <br /> County Ordinances, State Laws, and Rules 'and.Regulations:of the S.an'Joaquin Local Health District. Home' ewner or 1111' <br /> sed agents signature certifies the following:. . <br /> "1 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 t nsation laws of California." r <br /> Signed. . ........... .. <br /> ... ....... . ... <br /> ---- Owner. <br /> By ................ te. Title........ . . . G <br /> (if other than owner <br /> r <br /> { <br /> FOR DEPARTMENT USE ONLY 1 <br /> --�==�--'-�-•------_��__ter--=.-�— —_ _.^ '._ — -_ <br /> APPLICATION ACCEPTED BY ;1�_----.. DATE � ------ <br /> BUILDING PERMIT ISSUED ...: <br /> •-- -'- '`- ''- ---- ...:: ... '-- -' '---'-----....DATE ....... ...........}: ... <br /> ADDITIONAL COMMENTS <br /> '-'- <br /> . ._... ............. <br /> ............ ,.. ; <br /> Final Inspection by: ... - ;-'-- Date / 1.�.��................ <br /> 4SAN JOAQUIN�LOCAL HEALTH: DISTRICT <br /> _E-:-H_134 1268 Rev. 5M 7/72 3 M <br />