Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION-FOR t5ANITATION PERMIT <br /> (Complete in Triplicate) Permit Na. .-7��_3S___ <br /> ---------=----------------------------------------------- <br /> ________________________________________________________ This Permit Expires i Year From Date Issued <br /> 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 /> � 9 --------CENSUS TRACT --------_----------------- <br /> JOB ADDRE55/LOCATION = <br /> - ------ ------ <br /> _________________ _.___..__..---- <br /> Owner's Name - ----- --- -- -------Phone ------------------------ - <br /> Address ------------------ d -------- ------ -_..- - --t,G - --------- --- City r <br /> - ---------------------------------------------------------- <br /> Contractor's Name ----------- --- ----- ------- ---- ____j------------.License # Phone ------------------------------ <br /> Installation will serve: Residenc [ Apartment House❑ Commercial.❑Trailer Court :E] \J� <br /> Motel ❑Other -------------- ------------------------ <br /> Number of living units--------- Number of bedrooms -- -------Garbage Grinder ------------ Lot Size ----- _ __ _____ _______________ <br /> Water Supply: Public System and name ---------------------------------• -------- - ------- --------------------------------------------------------Private �. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [e Clay Loam ❑ <br /> 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'[ ] Size-- -------------------------------- ------ Liquid Depth ---------------------.----- <br /> CapacitY ----------- -------- Type -------------------- Material------------------.--- No. Compartments -------------------_ ' <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <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 ❑ No I❑ <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) ---------------------------------------------------------------------------------------------------------_-_-.---------------------------- <br /> s sal Field (Specify Requirements) -- � <br /> Y . <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 a ation laws of California." <br /> Signed ---- ---------------------- - Owner <br /> BY ----- --------------------- -- Title <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - ___-- - ----. DATE -- .'_-�- --ZI --------- <br /> - -- ----- ----------------------------------------------------------- <br /> BUILDING PERMIT ISSUED ------------- --------------------- ---- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS - --- --------------- --------------------------------- - ----- ------ --- - ------------- -------- ------------------------------------------ <br /> -- --------------------- ------- ---------------- ------------------------------------------------------------------------------------------------ ---•- <br /> - <br /> ------------------------------ -- - <br /> ----------- ---- --------------------- - ---------------------------------------------------------------------------------- <br /> Final Inspection bY: ------ ------._Date ---- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. SM <br />