72-195 - Laserfiche WebLink

Home Browse Search

I �r f FOS OFFICE USE: -r APPLICATION; FOR SANITATION PERMIT ----- Permit No. (Complete in Triplicate) ----------------------------•------------------------ ----- I ------- This Permit Expires 1 Year From Date Issued Date Issued I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein, described. This application is made in compliance withi'County Ordinance No. 549 and existing Rules and Regulations: • JOB ADDRESS/LOCATION .__-�-9 ----�,---�'--i �'�..1f-------------- --------------------------------CENSUS TRACT -------------------------- i � Owner's Name -----Pox-�-:e -�------- # - Phone --- (p Address --_`_ -------- --------- ---------------- -- -- ----- : - C;tY --------------- --------------- ----------- 4 -e✓` '`' �`''`'/�'✓ License # _ � �s Phone . -`' Contractor's Name _._ _ ___ ___ Installation will serve: Residence Apartment House-E] Commercial :❑Trailer Court ',❑ • Motel ❑ Other . _ Garbage Grinder ______ -_._ Lot Size _____ .__ '-..✓____________ ------- Num er living unity-__ Number of bedrooms—] _, ti Water Supply: Public System and name --------------------------�___________ _____________________ Private - ------- ----------------------------------- Character of soil to a depth of 3 feet. , Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Wardp ❑ (an 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.) W NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) j PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid -� , Depth -------------------------- Capacity -----_-_-_-_-_- Ca acctY ---- ----- - ------ TY+pe -----�_____________ Material________________�- No. Compartments ________________ •Distance I to nearest: Well ------'�-----------------------------Foundation -----------------------Prop..Line ----------:--:-------- LEACHING LINE {3g No. of Lines _______�__-__________ Length of each line--------4_U___-____ Total Length{,_-___ ...... 'D' Box -- ----- --- Type Filter Material ..........Depth Filter' Material ------��5;111___`%____ ---------------- - Distance to nearest: Well _---_-J- __�_____ Foundation Q- ------- Property Line. ___/ ------------ 1 rte, SEEPAGE PIT Depth ----- ---I------ Diameter _.r - --_ Number Rock Filled Yes ®' No l❑ Water Table Depth ---i--- --- 5;"45)_ ---r ---•---.Rock Size ---------11-----------------------Foundation __._/_ �_ Pop. Line _._ __'` Distance to nearest: Well .___1_ ...... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------�-'--. -f------------- Septic Tan (Specify Requirements) ____________________ _ __ __ ------- ) - ---------- Disposal Field (Specify Requirements) ------------- ------- ------- f -------------------------------------- ------------------------------------------------------------------------------------------------------------------------ -------- --------------------------------- (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 ithis permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws;of California.” Signed - ---------------------- -----'I----------------- Owner T BY ------- -'� -------- /---------- itle L '_ ------------------- `(If other than owner) R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __-- '-- - _- - ----------------- - DATE ----- --1.=- - _=-_______ BUILDING PERMIT ISSUED -- - ------'------------------ �_. -------DATE ------------------------- ------------- ADDITIONALCOMMENTS - --- ----- ----- ------'------------------------------ ----------------------------- ------------------------------------------------ ------------------------------------------------------------ -- �--------------------------------------------------------------------------------------------------------------- -------------------- Final Inspection b _y ------------ --•-------------------------------------- Dater ern 2 p Y Q SAN JOAQUIN11 LOCAL HEALTH DISTRICT �J , E. H. 9 1-'SS Rev_ 5M