72-667 - Laserfiche WebLink

Home Browse Search

FOR OFFICE uSE: r� / APPLICATION FOR SANITATION PERMIT �- --------------------------------- �" -- Permit No: (Completelin Triplicate) ---------------------------------------------------------- {' __ ___Z�__ !_L ----_----------------.---------------:--------- This Permit Expiresl Year'From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein t described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: _�� ;I JOB A DRESS/LOCATIONNI .0 _s _3 ._ l_._ 't�-L{�e�yr CENSUS TRACT --------- ...... Owner's Name - ---------,-Affe- ----- 'ol Phone'0t_--- V7&......_.. % Address ------ �-_kl r[- --- /t .... City - ---- Contractor's Name ------------- --- ----- -- -- ----~ --- $TitJ-------.License # _aU1.5�I----- Phone --�{�-&-` 6 •rl- Installation will serve. Residence"Apartment House ❑ Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units:-----(__._ Number of bedrooms ______Garbage Grinder __-_._______ Lot Size/3S Il -�ye�.`_ll U Water Supply: Public System and name -----------------------------------•---------------- ---------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT � SEPTIC TANK Size__-�- -x_�-�--------------------- - -- Liquid Depth -_-��:._.-•----..... � Capacity ��,�_ ___ _ Type __ __ Material_._C ___ No. Compartments �-� - ---------------- Distance to nearest: Well ___________________________________Foundation _/0------------ Prop. Line � �........M Total Length 'D' Box ------ Type Filter Material ____________________Depth Filter Material --------4g__`'_____.__._____...___-_ Distance to nearest: Well _______________________ Foundation _______1....---- Property Line ----�--------------- r rr SEEPAGE PIT Depth _.__ _ __d_. Diameter kr - Number ----.__y-------------- Rack Filled Yes'V No 0 4 �� Water Table Depth ---------------------------------------------..-Rock Size i Distance to nearest: Well .______________________________________Foundation - Q=___.---- Prop. Line _._._ __,...._. _ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------..___.__...:_.__) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------:----------------•--------------------------- DisposalField (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ---------------------- --- - ----------------------------------------------- -- ----------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner 4 as to become subject to Workman's Compensation laws of California." Signed ----------- Owner - - ---------- - -- --- - ---------------------------------- - �Qxt------------------------ ------ ------- --------- BY ---------- r' x/1.1-------- ---------- - ------------- -----------------------. Title ------ (If oth han owner) FOR DEPARTMENT USE ONLY ACCEPTED BY ---C=---- -------- -- ---------------------------------- -----------------------------------. DATE /Z.J/ -- ------------------ APPLICATION BUILDINGPERMIT ISSUED ----------------------- ------- -------------------------------------------------------------------DATE ------------------------------------------ ADDITIONAL COMMENTS -- ----- __ _ �____ ____ -------------------------------=--------------------------- ------- -- -- - ----------- ----------- ----- r--------: � --- �- ------ �I.' ----------- ------------------------------------- ------------------------------ ---- ---- - ----=------ Final Inspection by -` I----------------- '-- - -- --------------Date �-------- ---- --------- --- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT H. 9 1-'68 Rev. 5M.