Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------- ------------------ Permit No. �--"`J <br /> k (Com.p�a 1n Triplicate) <br /> --------_-------------_---_------ This Permit Expires Year From Date Issued Date issued _ - _-_7-'? <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 ------ ��r �-5` �� ` --------------------- -- ------CENSUS TRACT --------------- -----•.__. <br /> Owner's Name ------ ----------------------------------------------- ---- <br /> ._Phone 2 ------------- <br /> Address --O*0/-®_.0-----, �,-C-- -------------------------------------- City __ f G K Q/!-------------------------- <br /> Contractor'% Name -------- 5Z-7-774 _______-_ < ---_____._____.License # 112'-7-8�'V_ Phone <br /> Installation will serve. Residence [&Apartment House❑ Commercial ❑Trailer Court f:] <br /> Motel ❑ Other ------------ ------------------------------- / <br /> Number of living units:____ _____ Number of bedrooms .__----Garbage Grinder A10---- Lot Size/,$_V__✓.t/_A--S_ r <br /> Water Supply. Public System and name ----------------------------------- --------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt C] Clay ❑ Peat❑ Sandy Loam E] 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 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size f p-I�-� q p <br /> ..l�J-7 Li uid De #h '%r------------------- <br /> Capacity/ _0� __ Type f� MateriaJ �No. Compartments _________________ <br /> Distance to nearest: Well ---------------------------Foundation _.l_Q__f________ Prop. Line __f--.--____--___-__ \p <br /> LEACHING LINE KNo. of Lines ---- --- ------------ Length of each line----7�-------------- <br /> Total Length -___-_--___-____ \► <br /> 'D' Box Type Filter Material __,( _4K-Depth Filter Material --- _Q-_--------------------------------- <br /> Distance <br /> .--___ _Distance to nearest: Well __, `4-------------- Foundation __LQ_- ---------- Property Line __.�----______. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ___-__-________ __________.____Foundation ____________________ Prop. Line ------------------- <br /> REPAIR/ADDITION <br /> .______--________REPAIR/ADDITION(Prey. Sanitation Permit# -------- ----------------------------------- Date __________-_______________-____-..) <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------------- ` <br /> DisposalField (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------ <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 become subject to orkm Comnsation laws of California." <br /> Signed --------------------- ---------- Owner <br /> BY ----- ---------------------- --------- Title ------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _-_-- of=---'- - ------------------------------------------ -- <br /> --------- DATE ------------- <br /> BUILDING PERMIT ISSUED ----------------------- ------------DATE ----------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------- --------------------------------- -- ------------ -------------------------------------------------- <br /> -------------- <br /> Final inspection by Date --------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />