Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _ - __- ____-. <br /> ------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 .___ _ __ _, ' _`sa!'7�_..__.____._.___-_CENSUS TRACTS'�,�_________ <br /> - ------- -------------- --- -------- <br /> Owner's Name ( G -------------------•-•----------------------------------------- -------------Phone ------------------------------------ <br /> Address City •�-'��-�i �------------------ <br /> -------------------------------- <br /> Contractor's Name ------� ---------------------------------- -------------.License # --------- ------ Phone <br /> ------------- - --------- <br /> Installation will serve: Residence R_Xpartment House❑ Commercial ❑Trailer Court ;❑ \ <br /> Motel ❑ Other -------------------------------------------• <br /> Number of living units:_._------ Number of bedroofns ____Garbage Grinder ____________ Lot Size ----`--------______________ <br /> Water Supply: Public System and name ------ l.*�r QY' ----------------------------------Private El <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,j <br /> PACKAGE TREATMENT [ j SEPTIC TANK I j Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity ------------------- Type -------------------- Material---------------------- No. Compartments --.................... <br /> Distance to nearest: Well ____________________________________Foundation -------------- ------- Prop. Line ___.__________________ <br /> LEACHING LINE ( j No. of Lines ----------- -- Length of each line---------------------------- Total Length ----------- ---------------- <br /> r <br /> r.. 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -----------------_------------------..---_._ <br /> fDistance to nearest: Well ------------------------ Foundation ------------------------ Property Line _____._____-____-_.__�` <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> f Water Table Depth --------------------Rock Size ----------------------------__ <br /> A <br /> Distance to nearest. Well ________________________________________Foundation __----------------- Prop. Line _-_______-______._____ <br /> f' REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________________________________) <br /> SepticTank (Specify Requirements) ----------------//-//--------------------------------------------------------------------------------------------_--------------------------- <br /> Disposal Field (Specify Requirements) _____u/ _Zt. �-•- <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 becomes .blect to Wor an's Compensation laws of California." <br /> Signed —Y-1441 ----- hCG? --------------------------------------------- Owner <br /> BY --------- ------------------------------------- ---- --- ----------------------------------- Title --------- -- w <br /> (If other than owner) <br /> FOR DEPARTMENT(USE ONLY <br /> APPLICATION ACCEPTED BY ______ _ __ 4_._ _ - ��`��~ <br /> ---- --- - ------------------------------------------------------------ DATE --------�-------------------------------- <br /> BUILDING PERMIT ISSUED -------------------------- DATE ------------------------------------------- <br /> � Na <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------- `+----------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- - ------- -------------- -------------- --------------------------------------------------------------------- <br /> - -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------- - ----------- - <br /> Final Inspection b Date Z- � T�. <br /> p Y ------------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />