Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- - � _r-3-���_ <br /> (Complete in Triplicate) Permit No. <br /> --------------------- ------------------------ <br /> This Permit Expires 1 Year From Date Issued Date Issued '73 <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. 549 and existing Rules and Regulations: <br /> I <br /> t JOB ADDRESSAOCATIO ------ `7 - --------CENSUS TRACT -------------------------- <br /> Owner's Name -------- i% one <br /> Address - -- ------ - <br /> ----------- --- ------------------ City ---- ---------------------- ---------------------•--._....------ <br /> 38 7- <br /> Contractor's Name ----------------------- --------------- � .License #lQ_.. Phone --------------•--------------- <br /> Installation will serve: V Residence.[] Apartment House^❑-Commercial ❑T�ler ourt i❑ <br /> Motel ❑Other __i, A- _ <br /> Number of living units:------------ Number of ms ____---_-___bedrooarbage Grinder --------- Lot Size __._--------- --------------------- <br /> F <br /> Water Supply: Public System and name ----------------------------- -------- _----------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ Peat❑ Sandy Loam ry Clay Loam <br /> h <br /> Hardpan ❑ Adobe:[] Fill Material ------------ If yes, type ---------___________________ <br /> t <br /> r <br /> (Prot plan, showing size of lot, location of system in relation to..wells, buildings, etc, must be placed on reverse side.) <br /> k NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �I <br /> t rPACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth _________..________:___ <br /> Capacity - Type _____________ ______ Material------f--------------- No._Corn portments <br /> Distance to nearest: Well __-_______________________________Foundation --------------------- Prop. Line _-__---_-_-_-__---_. <br /> J <br /> LEACHING LINE [ ] No. of Lines __ ______________________ Length of each line----------------------- Total Length ___________.___......_.____. <br /> 'D' Box -- ----- <br /> -- - Type Filter Material -------------'-------Depth Filter Ma --terial .-----------------._........._. <br /> E _ J / <br /> Distance to nearest: Well ---_-___-__--_-_----__ Foundation .--_--_______--- ---- Property Line --_-_------------------ <br /> SEEPAGE PIT [ ] Depth ____ --------------- Diameter ---------------- Number ------------------- _ Rock Filled Yes Q No .0 <br /> Water Table Depth ---- -------------------------------------------Rock Size ------- ------- -------- <br /> Distance to nearest: Well ----------------------------------------Foundation ......�'----------- Prop. Line ------------- ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------:--------------------:-__ Date -------------------------------_7f <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------------------------•--•--------------------------------- <br /> Disposal Field (Specify Requir ents) ----------------------------•-------------------- ,.� <br /> _-_____. -_ -_ <br /> �! � <br /> G'------ --------------- - <br /> - f <br /> ----------------- <br /> - -- _ Q <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 become subject to Workman'spensation laws of California." <br /> Signed --------- . -- Owner —�� <br /> By -------- ------------------------- itle <br /> ------------------------- - <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .- `°-- -- ---------------------------------I---------------------------------------------- DATE --- --e... .2 4')-_�7-3------ <br /> BUILDING PERMIT ISSUED - -!------------ -----------------------------------------------------------------=--------------DATE <br /> ADDITIONAL COMMENTS ------------ f---------- - <br /> -------------------------------------- <br /> t <br /> -------------------- - <br /> - --------- <br /> ----------------------------------------------------------------------- <br /> -------------- <br /> - --------------------------------------------------------------------------- <br /> ---------------------------------- -- -- - ---------- <br /> ------------------------- <br /> --------- <br /> Fina! inspection b d ------- --•----- ----------------------- ------------------Date ---- ---_ _-�----------� <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> hk <br /> E. W. 9 1-'b8 Rev. 5M <br />