Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------- - --------- -------- Permit No, _7/---- <br /> (Complete in Triplicate) ----- " <br /> -------------- This Permit Expires 1 Year From Date Issued Date Issued -4-: P-7( <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 /> JOB ADDRESS/LOCATION .- - ---- <br /> - ' -Y..v f- CENSUS TRACT <br /> Owner's Name - ------"- --- � -� -•---- <br /> r `' ----- Phone <br /> Address [ '�'------ 7-7 --- -------------------------'-.,Cit <br /> Y = - <br /> Contractor's Name -- i- +'r_ 4-c`` �.� ______'License # fir._-_ Phone <br /> .-.- /_ 7 <br /> Installation will serve: ResidenceXApartment House ❑ Commercial ❑Trailer,Court ❑� <br /> Motel ❑ Other ---------------------------------- 1 <br /> Number of living units------------- Number of bedrooms _�-------Garbage Grinder ----- Lot Size -------------------------------------------- <br /> Water <br /> ---------- --------------------Water Supply: Public System and name ---------------------------------- -------------------- 1----------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑, Pe'at•❑� Sandy Loam ❑ Clay LoamL;;� <br /> Hardpan ❑ Adobe-❑ Fill Material-_-'--------- If yes, type -------__---_------------- <br /> F" 1 <br /> (Plot plan, showing size of lot, location of system in relation "to' wells,buildings, .etc. must be placed on reverse side.) <br /> C 4 \I� <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 1--------------------- Prop. Line --------- ............ <br /> LEACHING LINENo. of Lines 'Length !_ Total Length ---------------------------- <br /> ( 7 �-- -------------- of each line------ - - - ' <br /> t <br /> 'D' Box -------- --- Type Filter Material --------------------Depth Filter Material --------------------.--_--.----------.._---_ <br /> Distance to nearest: Well --------- -------------- Foundation ----- --- ---------- Property Line ----------_-_-.._:.__-__ <br /> � k 1 1 , <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------------------_- Rock Filled Yes ❑ No i❑ <br /> Water Table -Depth ------------------------------------------------Rock Size --- ------------------ <br /> A <br /> Distance to nearest: Well ----------------------------------------Foundation ------------------- Prop. Line _--- ----------- <br /> r <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date _----------,-- -------------------- <br /> Septic Tank (Specify Requirements) ------------------------------------------------- -------------- --- -�---_--�--- /f --� --------------------------- <br /> Qisposai Field (Specify Requirements) jr- -�----/ 1�-1 ---Cy ---- - sC______ _.______________ <br /> =' -- ..y.;, ..------------------------------------------------------------------ -----------------------------------I------------------------ <br /> ------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw <br /> ------------------------------ •I------------------------ <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: k <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 /> - --Signr ..a <br /> K! v. <br /> Sign _._� Owne'r <br /> ------------------ --- ------------- ----------------------------------------------------------- <br /> BY ---------------------- - Title .- -- _ <br /> ------- - - - ------------ <br /> ---------- <br /> (If other than owner) <br /> FOR DEPARTMENT JUSE O Y <br /> APPLICATION ACCEPTED BY --------------------------------------------- ------- i DATE 0� , X97/------ <br /> BUILDING PERMIT ISSUED ------ ------------------------ ------------- --------- --- ----._DATE _.----------------------------------------- <br /> - - ------------------ --- ----- -- --- <br /> ADDITIONALCOMMENTS -------- ---------------------------------------------------------------------- ----------------- --------- <br /> - -------------------------------------------------------------------------------------------------------- ------------------ <br /> Final Inspection by; ---------------------------------------- ------- ----- <br /> --- �lJ'� ' Date �t ��7----------- ------------ <br /> SAN JOAQUIN LOCAL HEALTH ICT <br /> E. H. 9 1•'68 Rev. 5M' <br />