Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> ____ ----------------------------------------------------1 �7< This Permit Expires 1 Year From Date Issued <br /> 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 inn compliance with County Ordinance N/o. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO 40"?2 .-___-- - ----- -- -- - ----- ---------------t5,P--._----------------------CENSUS TRACT ----S-��--•----------- <br /> 12 <br /> Owner's Name ------------- ----- ----------------- ----Phone ---------------- <br /> Address _ � __. City <br /> ------------------ - --------- - - ---- -- - ------------------------------------------ <br /> - <br /> Contractor's Name - t ------ --- -------- ---- ----- ----- , -.License # �de--��. Phone ---------------------•-------- <br /> Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:_________I_ Number of bedrooms ---- ------Garbage Grinder ____ ------- Lot Size -----------------------------------_________ <br /> Water Supply: Public System and name ---------------------------------•----------------------------------------------------------- ----------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam;R 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 f ] Size-------------------------------------- Liquid Depth -----------_-------._.---__ <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 Length ----------- ................ <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material --------.-----------.---------I............ <br /> . <br /> Distance to nearest: Well ------------------------ Foundation -- --------------------- Property Line _____________-____._-__. <br /> SEEPAGE PIT [ ] Depth ___ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth-4-----------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) - <br /> SepticTank {Specify Requirements) ---------------- ----------------------- ------------------ ----------------------------------------------------.--------------------------- <br /> Disp al Field ISpecify Requirements) __ __ _-. ------�' _____ ___ ____ _.___ _______ �,__ -------- <br /> > <br /> _ _. <br /> =L.L �w �, f -` -------.5'? <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's Compensation laws of California." <br /> Signed --- --------------------- -- ---- ------------------ Owner <br /> title <br /> BY - ------ -- <br /> L ----- ----------------- <br /> (If other than owner) &t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ------------------------------------------------ DATE 'S •----------- <br /> - ------------- --- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------- ------------- --------------DATE ---------------------------------------•--- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------=-------------------------------------------- ------------------------ ---- ---------- <br /> ------------------------- <br /> --------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------- --------------------- <br /> ------ <br /> ----- - -------------------------------------------------------------------------------- ----------------- <br /> Final Inspection by; <br /> ------------- _Date T ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> E. H. 9 1-'68 Rev. 5M <br />