Laserfiche WebLink
FOR OFFICE USE. <br /> tosr-a APPLICATION FOR SANITATION PERMIT <br /> - --- ------------ 3 s-xm!�--------- Permit No: ��- ----�. <br /> (Complete in Triplicate} <br /> This Permit Expires t.Year From Date Issued Date Issued --. <br /> ------------------ ------------------------------ ------_ <br /> Application is hereby made to the San Joaquiri Local Health District for a permit--to construct and install the work herein <br /> described. This application is made in compliance with ounty O dinance No. 549 and existing Rules and Regulations: <br /> JOB-ADbRE55/LOCATr's NamIO <br /> N /1 -------- <br /> - - ----.-CENSUS TRACT -------------------------- <br /> Ownee t' f <br /> ---- ----- Phone ------------------------------------ <br /> = t �Address ----- <br /> Contractor's Name .../-", - ----------------------------License #Z"o-'__ aneT--------------------------- <br /> Installation <br /> --Installation will serve: Residence ment House❑ Commercial ❑Trailer Court ;0 <br /> Motel ❑ Other ------------------------- <br /> Number of living units:--.--- Number o droo s _'--- ---- Gar a Gr' r �0 Lot Size _ /--- ------- <br /> Water Supply: Public System and name -- ----- - ---- ------ --- ---- --------------------- -- Private ❑ <br /> Chardcter of soil to a depth of 3 feet: Sand'❑ Si Clay Peat ❑ Sandy-Loam ❑`, Clay Loama[] <br /> Hardpan ❑ Adobe F11141I Material - if yes,type ------------------ ---------- <br /> (Plot ,plan, showing size of lot, location of system in relation to wells, buildings, efc.; must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![ ] Size-------------------------------- ~-------- Liquid Depth -------------------------- V <br /> Capacity --------- ---------- Type -------------------- Material---------------- =--- No. Compartments ------------ --------- <br /> Distance to nearest: Well ---------=--------------------------Foundation---------------------- Prop.-Line ------------.---.--_-• <br /> LEACHING LINE [ ] No. of Lines --------------------- Length of each line.------------------- - Total Ler►gtha---_----.----_----- <br /> Len ------ <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 [❑ <br /> e <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ---------------------------------------.Foundation ----------.--------- Prop. Line ----------_----------- <br /> REPAIR/ADDITION(Prev, Sanitation Permit# -._---------------------------------------- Date ------_----------__-_---_--------1 <br /> Septic Tank (Specify Requirements) ------- ----------- - ------------------------ -- -----------------I----------- ----------- ---------------------- <br /> Disposal Field (Specify Requirements} le�el <br /> - ------- -------------- <br /> ----------------- -----------------------W--------------{Draw existing and required addition <br /> dition an 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 "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"subiect to Workman's Compensation lbws of Coliforriia."' <br /> a <br /> Sig ned ------- ------ ------ - Owner <br /> BY Title !/r/ -------------- ------------------ <br /> (I ther owner) <br /> FOR DEPARTMENT USt'ONLY' <br /> APPLICATION ACCEPTED BY r <br /> - ------------- DATE ------- - --- � <br /> BUILDING PERMIT ISSUED _..- --------------- ` ' ± <br /> - - DATE -.. <br /> -- ------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------ - r = _ <br /> ---------- - -------------------------------------- --- ------------------------------ <br /> ' _ <br /> ------------------ ------------------ --------- ------------------------ ---------------------- <br /> ---------------------------- -- ^ ------------ ------------------------------------`---------------- ---------�� z ------- <br /> 7`-Final Inspection by: - ------ - --------------- -------------------------------Date ------ <br /> 5 <br /> ----S JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />