Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. - � <br /> = <br /> {Complete in Triplicate) <br /> -!2 <br /> ----------7-' 3 �� �J-- Date Issued I/_----------- <br /> This <br /> --------------- <br /> Application <br /> This Permit Expires 1 Year From Date Issued ., ; <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. 5.49 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATIOI-�l `---:----CENSUS TRACT <br /> - -------Phone �T- -- ----- <br /> Owner's Name ----- -- .----- - - t ------- - --- --- --- -- ------------------------------ <br /> - � - --------------------------------------------- <br /> ?P <br /> ---------------- -----•------- <br /> Address ------------------ <br /> ----- -- ----------- ------------------------- Cit 7 � ..----------- <br /> - <br /> Contractor's Name ------- _ -- License #�+�F1 ��----- Phon <br /> - ---- --- -- ------------- <br /> t <br /> Installation will serve: Residence paftment House-❑ Commercial:❑Trailer Court 1❑ <br /> Motel [:]Other ------------------------------------•-----. ' <br /> Number of living units:-.-/------- Number of bedrooms _t.-j,----Garba_ge Grinder �,-----_y- Lot Size �j�--'---����� <br /> 3 ' -'.......Private <br /> Water Supply: Public System and name-----=--------- -- '=- _=--- ------------------- - "` ------ - <br /> t l <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> x F <br /> Hardpan ❑ Adobe K Fill Material ------------ If yes, type ----------_---------------- <br /> F <br /> (Plot plan, showing size of lot, location of systemy<ir —relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION:,. (No septic tank or seepage:;p,it.permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT •[ I . SEPTIC TANK.[ I L. ,. Size Liquid Depth <br /> -< T, e i Material---------- ---- -- No. Compartments artments <br /> ►:._ Capacity„»"-.___.-.- - --.» yYP...3- <br /> . .....z P, t <br /> " Distance,. to nearest: Well - ------------------- -a----=--�'"--Foundation ---------------'------ Prop. Line -------------- --.-_-- <br /> 1� v.xa1 M <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length <br /> I D' Box ------ Type Filter Material ------------------- <br /> ,":Di <br /> _---------- - ----Depth Filter Material I <br /> ------------------------------------------- <br /> ,"""':Distance-to'nearest' Well ----- I <br /> t YP 1 r `- -----•-- <br /> ----- ---- Fbvndation•""_- ='"------ Property, Line -------------• <br /> -- Rock Filled Yes No 0 <br /> SEEPAGE PIT [ I Depth -------}---------*-- Diameter ---------------- Number` ------ ❑ <br /> Water Table Depth ------------------------------------------------Rock Size--------------- ----------- <br /> ------------Foundation ------------------- ----•-•---- <br /> . Prop. Line __..-----�' <br /> Distance to nearest: Well -------------------_---__- � <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------- -------------- ---------- Date --------------------------°-------1 <br /> Septic Tank (Specify Requirements) ------------------------- _ i�f��l'i0 ------- ---- ------�'----------- -------------------.-- - --------- <br /> Disposal Field (Specify Requirements) -- -------------- <br /> "�" <br /> t 4 y t 1 t <br /> --- ------------ - ----------�-- -------- -------� ------ <br /> ---- ------- - _ - _---------------------------------------------- --------------------------------- <br /> _--(Draw existing and required addition on reverse side). .�. ._ *;r <br /> �I hereby certify that 1. 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 rformance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become Able o Work dnr-'s Compen 'on laws of California." <br /> Signed --- ------- -- - - - - - ------------------ Owner <br /> w ------�`---- ----- Title s-------- ------------------------------------------ <br /> (If of er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- . - ---- <br /> 'c <br /> DATE ---- / - /-"C ------------ <br /> r- <br /> BUILDING PERMIT ISSUED ----------- ------------------ --------------------------- ---DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ------- ------------- ------------- --------------------------------------------------------------- <br /> ------------- ------------------------------------------------------------------------- ------------ <br /> - -- - - - =-------- <br /> ------------------------ -------- <br /> Final Inspection b Date . //� -t�=��----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />