Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------- - <br /> -------------- -- - ------- Permit No. -- __y.s3 <br /> (Complete in Triplicate) <br /> - <br /> -------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San oaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is m : <br /> Gade in compliance with unty Ordinance No. 549 and existing Rules and Regulations <br /> JOB ADDRESS/LOCAT N d__�-------- - ---------------------- ---------------------------------- -- ---- --CENSUS TRACT -------------_----------- <br /> i <br /> Owner's Name ------- -------------------------------- - ---- - ----- Phone <br /> Address ------- ----- --------- ------ ---------. City <br /> r r rp <br /> Contractor's Name -------License # _�d0: _ Phone ------------------••---------- <br /> Installation will serve: Resident Apartment House❑ Commercial :❑Trailer Court 0 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units------- ---- Number of bedrooms __.2'----Garbage Grinder ----- Lot Size <br /> Water Supply: Public System and name -------------------------- ------------------------------------------------ ----------------------- Private { j <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy LoamClay Loam <br /> Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <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 11 SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth --------------------,----- <br /> Capacity --------- ---------- Type -------------------- Material--------------------- No. Compartments ------------._..-__ � <br /> Distance to nearest: Well _____________ ----------------------Foundation ---------------------- Prop. Line _..___________--_---_ 0 <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each li'ne---------__------------------ 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 0 <br /> WaterTable Depth ----------------------------- ------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ____----______________________________Foundation ________-----__-__-. Prop. Line ______-____---....__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------------•---•----) <br /> Septic Tank (Specify Requirements) -------- ----------------------------------------------- --------------------------- ---------N -------------------------------------------------- <br /> - <br /> osal Field (Specify Requirements) ._ - c '�.---,°-1' 4 --- `--�z- --------------------- - - <br /> - <br /> '�'`------ _ L �' = ------ F <br /> ------------ ------------------------ <br /> ti <br /> ------------------------------------ - ---- ---------------------------------------------------------------------------------------------------------------------- <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 Wo an s Compensation laws of California. <br /> Signed ----------------------- ----------- -- ---- -- -- --- <br /> - -------------- Owner <br /> BY r Title <br /> ----------------------------------------------------- <br /> (If other th owner) <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _._--_--_____' __ _ DATE ---- ---4p/- <br /> Z-___frl�?Z <br /> BUILDING PERMIT ISSUED ----- - ----------------------------------------------------- ---------------------------- --------------DATE ------------------------- ----------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------- --------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ <br /> ----------------------------------- -------- -------------- -------------------------------------------------------------------------------------------------------------------------------- <br /> -- - <br /> ------- ------------------------------------------------------------------------------------------ <br /> iFinal Inspection by- --- ------------ - ---- -----.Date -------�-------'-7-�..-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />