Laserfiche WebLink
FOR OFFICE USE:, APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) Permit No: <br /> This Permit Expires 1 Year From Date Issued Date Issued------------------------------------------ <br /> l ___7J�. <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 /> I : <br /> JOB ADDRESS/LOCATION -----_[-RD`--------------------------------CENSUS TRACT --------------I---------_- <br /> Owner's Name ---------/A----- --------------•--•------------------------=-•-------------------Phone -55q----------------------- <br /> Address ---------/ __ -7------F=------Rj v ---------------------- City -= -�R_I_ 011 '--'----------------------------- - ............... <br /> S _ <br /> Contractor's Name ----------------------------J----------------------'--------.License # ------- --------------- Phone ------------------- <br /> Installation will serve: Residence ❑Apartment House-❑ Commercial❑Trailer Com t <br /> Motel �-------------- <br /> Z <br /> ` <br /> Other - J <br /> NmeNumber of living units:____ ubrof �drooms _ Garba e <br /> Grinder ------------ Lot Size _ <br /> C <br /> Water Supply: Public System andname---- = = € ----•----------------------------------------------------------=----- ------------Private �— <br />�' Character of soil to a depth of 3 feet: Sand 2�SiIt❑ Gay ❑ Peat❑ Sandy Loam ❑ 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 fest,) <br /> PACKAGE TREATMENT— T SEPTIC-TANK +rte--------------------------------f _-----"--'---Liquid Depth -------------------------- <br /> [ Size <br /> N <br /> Capacity -------------------- Type Material---i No. Compartments ----•---._--- y <br /> Distance to nearest: Well __�--------------------____--------Foundation ----------- Prop.tine ______________________ <br /> LEACHING LINE [r�No. oQuines ------------------ ------ Length of each line___?_:___t__________________Toto Length _________.___________,____ <br /> I 'D' Box -------- Type Filter Material --------------------Depth Filter Material --------------------•------------------•---- <br /> Distance to nearest: Well _____ __________________ Foundation J--------------------- Property Line _ <br /> -----------------•-•--- <br /> SEEPAGE PIT [ ] Depth = E__ _______ Diameter ________________ Number '_ ___S. _______._________ Rock Filled oyes ❑ No C]1 En i <br /> Water fable £'Depth _ ---------777 .•- Roc`k Size -----------"-------------- <br /> Distance to nearest: Wel! _______--------------------_____'__ _-_o ndation ---------------___)Prop. line ---------------------- <br /> I �' }} �v <br /> REPAIR/ADDITION{Prey.Sanitation Permit # ________.____________________ ___________ Dates__________.________.________Z_} <br /> 1 <br /> Septic Tank (Specify Requirements) -- --- $T--- ------------------------------------- ] <br /> Disposal Field (Specify Requirements} __.__.-___ pK _____/4T__- vr.4 _ ____`�-s{f0-----_54�.Raa&T --_ <br /> fr _Tl41v I'i�----------2----J-7S--------X-'--2v-- '� LEA:wH 4-�N ------- <br /> ------------ <br /> 1 = x = X=j-�----�----��.E_pp_��_ =p,7�- 1---------- ------------------------------------------------------------------------ <br /> (Draw existing and required addition on 'averse side) <br /> I hereby certify tha�'l have prepared, this application and that the work will be done in accordance with San Joaquin <br /> County OrdinancesState Laws, and Rules and Regulations of the. San Joaquin!Local Health District: Nome 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,it shall not emAy any person in such manner <br /> as to be�mnre•subject t Work n's pensati, laws of California." r <br /> Sign --- '-- ------- - -- -- ------'C�'------ ----------------- - --- Owner <br /> - - <br /> - --------------- -Title ------ -'------------------------- <br /> - ------- ---- ----------------- <br /> ------------------- <br /> (If other than owner); <br /> FOR DEPARTMENT USE ONLY 1 � <br /> APPLICATION ACCEPTED BY ----- !_. _.Q` - --------- ----------------•----------------. DATE ------ / f =------------- <br /> BUILDING"PERMIT-ISSUED-='.__------- "'_ . 'w " ------ --- - _,.�. <br /> = -------------DATE ­777-77-77­77--. ^ <br /> ADDITIONAL COMMENTS ` - -t1 ----------� \i - <br /> � .. -- - -— -- - ---------- <br /> -------------------------- <br /> ---------------------------------- ------- -------------------- <br /> - ------------------------------------------•------------------ / <br /> - - ----- --- -- <br /> Final Inspects : __ Date ` ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />