72-1074 - Laserfiche WebLink

Home Browse Search

FQR OFFICE USE: APPLICATION FOR SANITATION PERMIT --- - - (Complete in Triplicate) Permit No: ---------=---------------------------------------------- rr 'This Permit Expires i Year From Date Issued Date Issued 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/LOCATI N --Mq,3- 1G r SC �-` S-C 63-0-- ---Rd----- --------------CENSUS TRACT -----,--I--------------------- Owner°s Name �X-V'-\Q Y-'U- `L---- Luua)-------------------------------------------------Phone_ 1� `�. .4- .. qq f y� Address -----1 10 --------�- I-------- ---L------------. City ----Lo�------------------------------------------------------- Contractor's Name ---------------------------------------------------------------------------------------License # ------------------------ Phone ----------------------..:..... Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ❑ Motel ❑Other -------------------------------------------- Number ------------- ------------------------ --Number of living units:--Ll----- Number of bedrooms --3-----Garbage Grinder Lot Size ---"1ST- _-.dam _a----_----- Water Supply: Public System and name -------------------- -_-._Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ i Hardpan ❑ Adobe ❑ Fill 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,) / W PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size- a'� ---Ir Liquid Depth _----- _-------------- Capacity �, .-Q --.,-- Type ----------/-------- Material-------- No. C mpartments ... .:......... .... --� Foundation - --- Pro Line f L4 Distance to nearest: Well -7--2 ----------------------- - �.��, p f ._.-.__....... LEACHING LINE No. of lines _ j1 1 --�----•=----------- Length of each line - ------------- Total Len�th --------------- 'D' 'D' Box "13----- Type Filter Material _s_= ..........Depth Filter Material --_1-.----_------------------------------ Distance to nearest: Well ---CO'------------ Foundation f--------------------- Property Line _ ____________._.:.._. Diameter Number -----_-_--. .-_ Rock Filled Yes No SEEPAGE PIT [ ] Depth -------------------- ---------------- -----:------ „ ❑ 0 �'._� ize s- ------� ::Rock S' -�-= �------•--- _..... _ _ Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---_---_-.-.__----__. REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ------.---------------------------J r SepticTank (Specify Requirements) ----------------------------------------------------------------------------•---------------------------------•.----------------------------- Disposal ----------------•----•---••- Dis osal Field (Specify Requirements) -----•---------------------------------------------------------------------------------------------- --- ---- -- --- - - - ---- -------- ------ 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 Ordinantes, 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 any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------ --- -------------------------------------------------------------------------------------- Owner BY --------------------------------------------------------------------------------- -------------------- Title -------- -------- (If other than owner) FOR DEPARTMENT USE ONLY ACCEPTED BY 1 r ---------------------------------------------------------- DATE ) .�V ------------------ APPLICATION BUILDING PERMIT ISSUED --------- ----------------------- ---------- ---------------------------------=--------------DATE -------------•--------=- ----------------- ADDITIONAL COMMENTS ------------ --------------------------------------------------------------------------------------------------------------------- ---------------I----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------------------------------------------------------- - Final Inspection bY: a .�' --------------------------------------------------------------------- Date//- 2'-"------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M .