Laserfiche WebLink
_ !A OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> XPermit No <br /> ------------ - <br /> --------------------- - - <br /> (Complete in Triplicate) <br /> -------- -------------------------- Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> ---t--------- ' <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 /> �r� kk ,, pp� <br /> JOB ADDRESS/LOCATION ----- ----------- <br /> Owner's <br /> ---- - --- "` - CENSUS TRACT _ •----------- <br /> Owner's Name d� �Vr / 1 `+` ------------------------------------ ----------------- ---------------------------------Phone ------------------•--•----------•--- <br /> Address ----- L rf7-e.�o /LJ� ------------------------------ ------------ City ------------------------------------------- <br /> Contractor's Name -----------------------------------------------------------------License # ------------------------- Phone ---------------------•-------- <br /> . <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel XOther _-_ <br /> ��nOt1A -------- ------ <br /> �b_ ------. <br /> Number of living units------ Number of bedrooms -1------Garbage Grinder A4 __ Lot Size __6S_-ACrt---------•-------- <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------------- -----------------PrivateX <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 sidely J� <br /> i .: <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 240 feet,) N <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth --------------------- --° try <br /> 1 � j VI <br /> Capacity _- ar`�_----_�'4 Type�«--' --`- Material- Are 1 --- No. Compartmenfis - <br /> Distance to nearest: Well ---- Qt------- _________Foundation ---I_D.-_----------- Prop. Line _____ __ ____________ <br /> E +�oe <br /> LEACHING LINE [ ] No. of Lines _..+�________________ Length of each line-_----9_ _------------- Total Length ---1-.____-____-________..- <br /> cc, y e <br /> 'D' Box --_-- Type Filter Mat'rial S_� _Depth ilt r Material -----___I _�________....j------------- <br /> F i <br /> Distance to nearest: Well _,SV+-_--___.Foundation Property Line. __19_________________ <br /> ------------------------ <br /> SEEPAGE PIT [ ] Depth __,_ --------------.Diameter ---------------- Number ---------------------------- Rock Fiil d Yes ❑ No i❑ <br /> Water Table Depth ----------------------------- - ------••----Rock Size <br /> Distance to nearest: Well -------------------------- ....Foundation _____ Prop. Line ...------------------ <br /> - ------- --------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------- ---------------4--`-- ---------- Date ---------------------------------- <br /> Septic Tank (Specify Requirements) --------------------------- - - *�, - -. - <br /> Disposal Field (Specify Requirements) ------------ ---------- ----- ---------- -->------ ----- -"�`- ------------------------------------------------ <br /> f� <br /> -------------------------------------------- - 4 <br /> ------------------------------- r <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. Nome owner or licen- <br /> sed agents signature certifies the following: I <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 /> Sig - ---------------------- ------------------------ Owner <br /> By - -- LY _ <br /> - cakEri.--- --- ------------------------------- Title ------------------ ----- ---------------------------------------------- <br /> otherthan owner) <br /> It FOR DEPARTMENT USE ONLY ` <br /> APPLICATION ACCEPTED 13Y ---- ----------'----- ---------------------------------------- DATE ------------ -------------;;------- <br /> BUILDINGPERMIT ISSUED . ---------------------------------------------------------------------------------------------DATE --------------------------------z--------- <br /> ADDITIONALCOMMENTS ----- ------------------------------------------------------------------------------------------------------------------------ ------------------------------- <br /> --------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ <br /> ------------ — - a ---------------- <br /> -------------------------------------------------------------------------------------------------------- -- --- <br /> -------------------------------------- --- Date ----q--r- - -f <br /> FinalInspection by: - --- �------------------------------------- -------------------------------------------------- -------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E_ H_ 9 1-'68 Rev. 5M VT <br />