Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------------------- <br /> --- -------------- (Complete in Triplicate) Permito- - - -------------- <br /> ---------------------------------------- ------ I <br /> Dote Issued -----------._.------ <br /> --------------------------------------------------------- This.Permit Expires 1 Year From Date Issued <br /> Application is hereby made to,'fhe Scipjoaquir]_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 .------------------------ -------------------------------------------i---- ---------- ------------CENSUS TRACT -------------- ----------- <br /> Owner's Name --------------------- ''' _ _ ...:---------------------- --------------------------- -----------_- ------------ ------Phone ------------------------------------ <br /> Address ------------------------------------------------------------------------------------------------------- City - �-I�------------- <br /> ----------------------..._..--- <br /> 'e # PhoneContractor's Name ----------------------- Li . <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court ;0 <br /> Motel ❑ Other ----------'------------------------ '---- <br /> Number of living units:------------ Number of bedrooms -------1----Garbage Grinder ------------ Lot Size _______________________________________.... <br /> Water Supply: Public System and name ------------------------------= ----------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ f 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 lrelation to wells, bluitdings, etc, must byei placed on reverse side.) <br /> NEW INSTALLATION: (N�o�septic tank or seepage pit/permitted if. public isewer is available within 200 feet,) <br /> PACKAGE TREATMENT r[ ]. SEPTIC TANK.[ ] Size________________ - <br /> _________ Liquid Depth ____-_.__.._____________. <br /> CapacitY ---- - ------ ------- Type -------------------- Material----------------------- .No. Compartments ---------- -----_.._. <br /> Distance to nearest:.-Well _____________________________.__e_Foundation __--_------____ .i____ Prop. Line ---------------------- <br /> LEACHING LINE [ ] No of Lines -; �_Y--_____________ Length of each line--------------------- Total Length ,_____-_______________:___- <br /> i <br /> 'D' Box�J_J------ Type Filter Material -_-_--;__-- _-Depth Filter Material i----- -------------------------------------- <br /> Distgnce to nearest: Well ------------------------ Fou;dation -------------- --------- Property Line -----------------_--- <br /> SEEPAGE PIT [ ) Depth --------------------- Diameter ---------------- dumber ---------------------------- Rock Filled Yes ❑ No C-j <br /> Water Table Dep#h� '- -��. .� t '�<. -----------Rock Size <br /> i -- ---------------- - <br /> t+ <br /> neg. ----- --------Distance tqaW ----------::---- _Foundation ----------------+ddI <br /> I <br /> Prop. Line -------------- <br /> REPAIR./ADDITION(Prev. Sanitation Permit# -------=-------------- ----------------`4- Date ------------------------------___-) <br /> Septic Tank (Specify Rel'uirements) ------------------------------�------------- ---- --,-- ----------------------------------- I :..--------------------------- <br /> I F 't <br /> 11 <br /> Disposal Field (Specify Requirements) ----------- ------------------------------------------------------------------- --------------- <br /> � s <br /> -------------- --------------------------- ------------ ------------------------------------------------------ ------------------•----- <br /> it q fI' I <br /> ! ----- <br /> (Draw existing and rec{uired addition oni 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 Ordinafices, State Laws and Rules and Regulations of the San Joe cluin Local Health District. home owner or liven- <br /> sed agents signature certifies the following: k <br /> "I certify that ift the performance of the work for which this permit is issued, I.shall not employ any person in such manner <br /> Y ,i as to become subiect to Workman's Compensation laws of California." <br /> Signed --------- ---- -------------- s------ ------------------------------------------ ------------ Owner I <br /> r ; <br /> BY ------------------ -------------------------- `- = Title --------- <br /> (,If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION :BY -------------------------- i F <br />' -------------- DATE __.. <br /> BUILDINGPERMIT ISSUED:-------------------------------------------------------------------------------------------------------------DATE -------------------------- ---------------- <br /> ADDITIONAL COMMENTS= ------- - I -------------------------------------- <br /> ) 3 i L <br /> - <br /> -------------------- ---------------------t----------------------------------------------------=------ ----------------------------•------------------------------------------------.. <br /> --- --------------- ------------------f----------------------------------------------- = -----(---------------------- �� <br /> --------- -- ------------- ---- ------------------------------------------------------------------------------------------------------------------ ------------------------------••----••------ <br /> FinalInspection.by: ------- -------------------------------------------------------------------------------Date -------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> A E. H. 9 + 1-'68 Rev. 5M F"' <br />