Laserfiche WebLink
-X s <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------------ -- ----------- '' Permit No. ---�1-_ ----_----- <br /> (Complete in Triplicatel <br /> -------------------------------------------------- <br /> -----------------------------------------------_-__----- This Permit Expires 1 Year From Date Issued <br /> 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. 1 <br /> JOB ADDRESS/LOC TION ._ _ �-_ :�_----' '____.._CENSUS TRACT ______S-__f _ <br /> Owner's Name _�' -------------------- -------------Phone�. ys:7 N -- <br /> Address __Ref-__ _ _ ._ <br /> t <br /> .���-----------=-------------------------------------'----------. City _ - <br /> Contractor's Name - _.d! " - - -- -------- ----------------License # s '),237--- Phone <br /> --Installation will serve: Residence &Apartment House❑ Commercial :❑Trailer'Court ❑ 1 <br /> Motel ❑Other -- ------ ------------------------ <br /> a <br /> Number of living units:_.-1------- Number of bedrooms -_3-----Garbage Grinder -------,-_ . Lot Size ----q- <br /> ................-- ____________________ <br />` Water Supply: Public System and name -------------------------------------------------------------------_--- -----------------------•----3-- Private t` <br /> Character of soil to a depth of 3 feet: Sand X Silt o Clay .❑ Peat❑ Sandy`Loam El Clay Loam:❑ <br /> Hardpan ❑ Adobe ❑ Fill Material _l: �_-_If yes, type ___________________________ <br /> (plot plan, showing size of lot, location of system in relation to lwells, buildings, 4ti, must be placed on reverse side.) s 1 <br /> NEW INSTALLATION: (No septic tank or seep e�pit permitted1f.public sewer is available within 200 feet,) >s <br /> PACKAGE TREATMENT SEPT TA K� Size--- ----------- Liquid <br /> > - � Depth ---� ____________=_-_-_-_ <br /> Ca ac•tY Type - L, ateria ,__ o. Compartments -------- <br /> € - <br /> V <br /> 4 istance to nearest: Well ----7�------------------------Foundation__—`--,1�-_r_______- Prop. Line ___ _____---_-• }� <br /> LEACHING LINE No. of Lines -------3-------------- Length of each line-----5-.-_--_____._____ Total Length ,____ _h��....._____.. <br /> _ . <br /> '. <br /> Q' Box ___ _____._ -Type Filter Material la__ ________ _._Depth Filter,,Material _.____��______________________________ <br /> Distance to nearest: Well _7 p-'---.-_------ Foundation ---------- Property Line -.-.--_-____-_-_ <br /> ,^SEEPAGE PIT Depth - Diameter ________________ Nuihber ___._._----_-_._:___._.__ Rock Filled Yes No .C] <br /> Water Table Depth --------------------------------------- =------Rock Size -------------------------------- , <br /> Distance to nearest: Well ----------------------------------------Foundation ---------------.---- Prop. Line ---------------------_� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------• -------------------------------- Date ----------------------------------1 <br /> t <br /> Septic Tank (Specify Requirements) --------------------------------------- ----------------- ---------- --------------------- ------- -: -- • ---- ... <br /> i Disposal Field (Specify Requirements) --------------------------------------------- ------------------------------------------------ ; +# <br /> ------------------------------------------------------------ � -------------------------------------------.----_ ----------------------------------------------------------------------------- <br /> r <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-6ccordance-witl -San Joaquiin4 <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: Ii <br /> y <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 /> Signed -------------------- ----- ------- ------------------------------ <br /> Owner <br /> BY- If other than owner) - Title ------------------------------------------------------------------------ <br /> ( v <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 4 t - ---------------- -------------------------------------------------------- DATE -------- ---------- <br /> BUILDING PERMIT ISSUED ------------- DATE --------------- --------------------------- <br /> "' <br /> COMMENTS - -_ ----------- --------------------------- <br /> -------------------------------------- <br /> ----- -------- --- ------------------- -------- ----- ---------------- -- ----•-- ---- - ------------------------------=---------------------------------------------------------------- <br /> ------------------------------------- -- - - ------------------------------------------------------------ II--- --/- <br /> Date ---------------- <br /> y: <br /> Final Insp SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />