Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> . --......-` -- - Permit No. ---7- 3---y <br /> (Complete in Triplicate) <br /> ------------•------ -------- <br /> • Date Issued ._- <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. 549 and existing Rules and Regulations: <br /> .,� O,fd.�-------------- r,] _.._ <br /> JOB ADDRESS/LOCATION . - P' c> '1 ' ...��_ 4°�-(`-��-'-�(. Y - 1i'�`= ��`� --------------CENSUS TRACT .._U__ <br /> Owner's Name -_CS-i L I I---1_- ...:ti------------------•----------------- -------------------------------------Phone ----------------------------------•- <br /> -------- <br /> Address --------------------------------- r)`s ---------------------------------------- City ------------------ _- -------------------------------------•-------•------ <br /> Contractor's Name /")­ <br /> ------------------------------------License # ------- ---------------- Phone --------------•---•----•-_--- <br /> Installation will serve: Residence ❑ Apartment House-[] Commercial ❑Trailer Court ;❑ <br /> Motel Q Other .._ - - ''------.------- <br /> Number of living units:...../_---- Number of bedrooms -----Garbage Grinder ------- Lot Size ----- _•_________________________ <br /> Water Supply: Public System and name --------------------------•------------------------------------------------•---------------------------------Private [Ht' <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe [Fill Material ------------ If yes,type ____________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. 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 [ I SEPTIC TANK![ Size____________ ,:;s�—�-..-._-..---- Liquid Depth --------- ---------------- <br /> Capacity -1�`�'t1 .=: -_. Type 1'-�'-'..�a_� _._ Material.- C_. No. Com artments <br /> P <br /> x v <br /> Distance to nearest: Well ____________________________________Foundation ------------------- Prop. Line ---------------------- <br /> t') <br /> ___-_--__--•---______ I,) <br /> _-u1_...._..___. Length of each line--__._--_�`�� --..._ Total Length Y�� <br /> LEACHING LINE [ ] No. of Lines g <br /> 'D' Box _%<.'-:--._.- Type Filter Material - ------Depth Filter Material ....1 ___ ____________________________ <br /> Distance to nearest: Well ._422.12_`_____-____ Foundation -...../L-1------------- Property Line __ J_-__-_ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter----------------- Number -................._-..._-._. Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ---- -------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation ..........-------.._ Prop. Line ...................... <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ---------------- -------------------------- Date ----------------------_____._.---_) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- --------------------------------------------------------- <br /> DisposalField (Specify Requirements) --•---•------•-------------••--- -••---------------- ---------------------------------------------------------------------•---------- <br /> -------------------------------------------------- ------------------------•--------------•--------------------•-----•-----•------------------------ ----------------------------------------------------- <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 su 'ect to Wor n's C mpensation laws of California." <br /> Signed/_ . - J/� --- ---------- ------ Owner <br /> BY --v--`------ --- ------------- Title ------------------------------------------ ---------- -------------- <br /> (If other than owner) <br /> FOR DEPARTM NT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------- DATE .... --------------------- <br /> BUILDING PERMIT ISSUED ------- /- . -------- ----- DATE <br /> ADDITIONALCOMMENTS -- - --------------------------- ----------------------------------------------....-----------------------------.---------------------------------------- <br /> ------------- -----------_--------------- ---------------------------------------------------- ---------•------- -•--....---------••-------------------•-•--------------•-------•----------------. <br /> -- --- - -- --- ------------ --------------------- ---------------------------------------------- ...................................................... ------------ -------------------- <br /> ate----------------------------- <br /> Final Inspection b /�J_.....Date -...- .------- �---_--------------- <br /> SAN JOAQUIN LOCAL HEALTH D TRICT <br /> E. H. 9 1-'68 Rev. 5M C I 1 <br />