Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - -------------------------- --- --- Permit No. --------------- - <br /> (Complete in Triplicate) <br /> ----------------------------------------- -------- <br /> --------------------------- ---------------------- , <br /> This Permit Expires 1 Year From Date Essued Date Issued - ..= .3-- <br /> - <br /> X23 --e)3o - `Cy <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. - and pisting Rules and Regulations: <br /> at O tt l 9-M &VA 1 2-; , <br /> JOB ADDRESS/LOCATION �"_-O-- 'P---- d-±!- - ~- -t++ - ----a-_ -,�-`s'i• �'a"�'r'" CENSUS TRACT ------------ ------------- <br /> Owner's Name -- -/-1 -'- ------ -----------------------------------Phone <br /> Address --------- ---- -- ------------ --- Cit <br /> Contractor's Name /4 n-------•-4___1''`''=____-_%_� --------------------------------License # :-------- -.-- Phone .----------------------------- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:.-./-----.-- Number of bedrooms _°?_----_-Garbage Grinder ------------- Lot Size . ---------------------------- <br /> Water Supply: Public System and name ---------------------------------•-----------------------------------.- ---------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam R1 <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,) 9 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -----------------_--_--- p <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------I........ <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- .......... d <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length --------------------------- Ch_ <br /> 'D' <br /> ---------- ------ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------------- - ' <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. -------------.-.------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth -----------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} <br /> SepticTank (Specify Requirements) -- ---------------------------------------------------- -------------------- ------------------------------------------------ ------------- <br /> Disposal Field (Specify Requirements) �------� -. --�` �-----3.----- - t: -_---.-__---- <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 pe�#� orkman's <br /> rmance of the ork For which this permit is issued, I shall not employ any person in such manner <br /> as to beco su iect t en�atian laws of California." <br /> Signed -- .1.-- 7N- ------- -------------------------------- Owner <br /> BY ------------------------------------------------------------------------------------------------------ Title --------- -------------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ------------------------------------------------------------- DATE . ��-U- ��--• - --•--------- <br /> BUILDING PERMIT ISSUED -------------------------�. + <br /> --- - -- --- ------ ---- -----•---------------------------------------DATE ------- - ---------------- <br /> ---------- <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 />