Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT r � 3 <br /> Permit No.. - <br /> : (Complete in Triplicate) - <br /> --------------------------------------- <br /> ----------------------_----------------- <br /> ______;-----_--_ This Permit Expires 1 Year From Date Issued <br /> Date Issued _ .�MC7 <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 ADDRESS/LOCATION _ ,-----�5 �-1-1 ------------ ------CENSUS TRACT ------------------- <br /> —�,, <br /> Owner's Name ------ ✓�Ci - Com/ / �s -Q------------------------------------------------W_ 7 <br /> ----------- Phone.! <br /> Address d3, --;- -----. City _ ,���/7--- <br /> Contractor's Name _ h—,06:�5___ '------ ----------.License #I- - - Phone' � --------------- <br /> Installation <br /> ------------ <br /> F <br /> Installation will serve` Residence �partment House^❑ Commercial:❑Trailer Court ❑ <br /> Motel ❑ Other --------------------------------------------- <br /> Number <br /> -- ----=------------------------Number of living units:----)------- Number of bedrooms __9------ Grinder/.kV__CS--- Lot Size ............ <br /> Water Supply: Public System and name ------------------------------------------------------------------------- ------Private ❑ <br /> k <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ 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.) W <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public:sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK j j J Size-------------- --------------------- ------ Liquid Depth -------------------------- <br /> Capacity ------------------- Type -------------------- Material--_- ---- No. Compartments -----:----__ N <br /> Distance to nearest: Well --------------- ---10 ___________Foundation ---------------------- Prop. Line --------------________ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------------.--___ <br /> 'D' Box ------------ Type Filter Material )-----------------Depth Filter Material -------------------- ._-----------------_._ <br /> Distance to nearest.. Well ---------------- --'--- Foundation ------------------------ Property Line ------------------.:-- _ <br /> SEEPAGE PIT [ ] Depth _________ Rack Filled Yes ❑ No <br /> - -------------- Diameter --- - -- - Number ---- --- <br /> Water Table Depth -----------------------------I------------------Rock Size --------------- - <br /> Distance to nearest: Well ------------------ ' -Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------1--------------- Date _____________________________ <br /> Septic Tank (Specify Requirements) --------------------------------------`1----------------------------------------------------- ----------- - ,,.--------------------------- <br /> Disposal Field (Specify Requirements) ----f4--- -------------2-,t---- '3 ---._1` 9- E------------------ <br /> --------------------- --------------------------------------------- ----------- q <br /> -------------------------------------------- -------------------------------------------------------------------- <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 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 which this permit is issued, I shall not employ any person in such manner <br /> as to becom sub1 cfi to Work an's Compensation laws of California.'" <br /> Signed _ - � �1 -------- Owner <br /> By --------------------------------------------------------------- <br /> --------------------------------------- Title ----------------------------------------------------------- ------------ <br /> Iif other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __7t__-e_A------ -------------------------- DATE .+ r _____" __ <br /> 7- n-----6 --- -- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------- --DATE ---- -------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------=---------- ------------------------------------------ ---------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------=-------------------------------------------------------------------------------------------------------------- <br /> ----------------- ------------------------------------------------------------------------------------- <br /> ---------- <br /> ------------------------------------------------ ----------------------- ------------------------------------- ------------------ -- <br /> r� <br /> ---------- <br /> --------- <br /> Final Inspection by. Date ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> E. H. 9 1-'b$ Rev. 5M <br />