Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> Permit No. ___7 - y_ <br /> lComplete in Triplicate) <br /> ---------- ------------------"----------------------- 4- <br /> ____ __ <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 549 and existing Rules and Regulations. <br /> JOB <br /> p /_ �i� A- ---------------CENSUS TRACT -�- <br /> JOB ADDRESS/LOCATION ._ _O_- '-p--- A------/h------ �" - G� `�.,p� <br /> Owner's Name --------------- Phone _.. 61_ e U <br /> - -------- ------ ------ ------ - <br /> Address - - ------ L------- ------------ --- --------- City _ ------------------------------------------------------ <br /> -------- - -- <br /> Contractor's Name _._ Q— -s. .c. .------------------------------------------------------License # ------------------------ Phone ----------------------- ------ <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> MotelOther --- -------------------- <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 Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ FillMaterial ------------ 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 /> l` , <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) W <br /> -/ r !I / <br /> PACKAGE TREATMENT [ I SEPTIC��TTA�ANK Size__342_X�---- -& <br /> X- -.f Liquid Depth,l---------------.----oa <br /> Capacity -_-Z- a__ ---- Type -_ — Material---------------------- No. Compartments �----------..... <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ______--_.______--------.-Z <br /> 'D' Box ------------ Type Filter Material ------------•-------Depth Filter Material --------------------•----------------------- <br /> Distance to nearest: Well ------------------------ Foundation --------------------- Property Line -------------------:---- <br /> -10 <br /> SEEPAGE PIT [ ] Depth ---- ------ Diameter ________________ Number ------ -------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------------------ ----------------Rock Size -------------------------------- <br /> Distance to nearest: Well, ----------------- --_-Foundation �-------------------- Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____-________---------------------) <br /> SepticTank (Specify Requirements) ----- -------------------------------------------------------- -------------------------------------------------- --------------------------• - <br /> Dispo al Field (Specify Require ents) �1�� ,- ------ <br /> 7 <br /> ---- , ¢-�,� <br /> ------- ----------- ----- a <br /> �tA <br /> tQ-ri -- --------------------------------------------------------------------------------------------------- <br /> {Draw exi ng 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 hick this permit is issued, I shall not employ any person in such manner <br /> as to become suble orkman's Compensa laws of California." <br /> Signed - �- -- - - -- --- =------ ----- Owner <br /> ------------- Title -------------- ---- - ------------- ------ ----------------------------- <br /> f other than owner] <br /> OR DEPARTMENT USE ONLY <br /> I APPLICATION ACCEPTED BY _ s..t .. --------------------------------------------------- DATE _ -:. _"]' ------------------ <br /> BUILDING PERMIT ISSUED ------------------------- --------------------------- <br /> ----------------------------------- --------------DATE - ---------------------------------------- <br /> ADDITIONAL COMMENTS ----------- -------------------------------------------------------------------- ------- <br /> ---------------------------------------------------------------------- <br /> - <br /> -------------------------------------------------------------------------------------=-------------------------------------------------------------------------------------------------------- <br /> ------------- --------------------------------- - - -------------------------------------------- --------- -------------------------"- ---------------------------------------------- <br /> ---------------------------- -- -- <br /> ----- ---- V <br /> Final Inspection by: . ---------------------- Date <br /> - --------------------------- <br /> SAN JOAQUIN LOCAL HEALTH,. DISTRICT W-�444--. <br /> F W 9 1.,hR RPV_ 5M <br />