68-566 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: ------------ ------ --_�Qj APPLICATION FOR SANITATION PERMIT : (Complete in Triplicate) Permit No. . _-_ �� -------------------- --------------_ This Permit Expires 1 Year From Date Issued Date Issued _--= l�``� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC TION _ � _- ---------- ------ ---- ------------- ---- -------- -----CENSUS TRACT --------------- Owner's Name - (J'. -- - ----�--'----J - - ------------------------------------------ ---------------------------- --------Phone ------ -------------------------- Address -_1.x0_- , LJ_ Cit ""�`7.- Contractor's Name -.--_---- __ 1 License # ------- - -------------- Phone Installation will serve: Residence qr-k-partment House,❑ Commercial:[]Trailer Court ;❑ Motel ❑ Other----- ------------------------------ Number of living units:----- --: Number of bedrooms -- ----Garbage Grinder.--- Lot Size -:�� _�_ -------_--_ Water Supply: Public System and name ---- ------ ----_-- Ir------------ -------------------- ----------------------------------------- -------Private ❑ Character of soil to a depth of 3 feet: Sand'Q Silt❑ CIO ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ Hardpan ❑ Adobe 9Fill Material ------------ If yes,type -------------------- --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic#tank or seepage pit permitted if public sewer is available within 200 feet,) p PACKAGE TREATMENTl 1 [ ] SEPTIC TANK C ] Size----- ---------------------------- ----------•- Liquid Depth -------------------------- C,] Capacity ------------------ Type -------------------- Material---------------------- No. Compartments ------- V I Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------•___-- (� LEACHING LINE [ I No, of Lines ----------- ----_-_ Length of each line---------------------------- Total Length -_---------- - - ------•------ 'D' Box ------------- Type Filter Material --------------------Depth Filter Material --.--.--_-------_ -,_ l Distance to nearest: Well --_------------------- - Foundation --------------_ Depth ------ -------- Property Line ------_- SEEPAGE P1T ---- ------- Diameter ------------ ---_--_--_----_ Rock Filled Yes ❑ No 0 [ l Water Table Depth _____________ ---------------------------------Rock Size Distance to nearest Well ---------------------------------------Foundation -------------------- Prop. Line ------------------- 1 REPAIR/ADDITION(Prev. Sanitation.Permit# -------------------------------------------- Date -------------------------__-_-- Septic Tank (Specify Requirdments) -------------------------------------------------- --------t ` r , �j ---- -------------------- ------------------------- Disposal Field {Specify Requirements} ___'YJ �___-_G_] $T--__-Qa .33 4�2� - ----------------------------- -- ---------------------- - n ---- - - ------------------------------------------------------------------------------------------------------------------ • - (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies,the following: ) "I certify that in the performance of-the-work.for which this permit is issued, 1 shall not employ as to become subject'to Workman'sXampensation lows of California." p Y any person in such manner Signed ---- ------------------ ----------- ---------------- ---- Owner ---- ---------- - - By --- ---- Title - ------------------- ( other than owner) ----------- ------ { r ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ` ' - ----. DATE -- -- - --- - - --------•------------------- ADDITIG PERMIT ISSUED ------------ I ------------- - -----------------------=--------------DATE ------ ---- ------- ----------------------------- - ONAL COMMENTS ----------- l --------------------- ------------------------ t---- --------- ----------------------- ------------------------------------------------------- -- ------------------ Final Inspection by: ---- ----- -----------------•--------------------------------------------------------------- ------------ �. t _r-`-�---------------- ----- - - ------------------ -------- - ------------ ---Date _.SAN. JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M