Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------ . Permit No,�--- l Log-- <br /> (Complete in Triplicate) <br /> .......... ���---- ----- � �- <br /> ---------- -------b- - <br /> This Permit Expires 1 Year From Date Issued 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 /> JOB ADDRESS/LOCATI N --------,----"'----"C----4f-------------------- -- -------- ------------ --CENSUS TRACT ------•---- <br /> r <br /> Owner's Name .. --------------------------------------- - ---- -- Phone - ---------------------------------- <br /> Address ------------ -- -------------------- Cit -- ------------------------------------------------------ <br /> Contractor's Name ------_ -- - --- -- ---- ---- _ ------License # fPTj9yPhone ------------------•-----_-__ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑Trailer Court C <br /> Motel ❑ Other -------A -- <br /> Number of living units:---10____ Number of bedrooms ._____.__--,Garbage Grinder ------------ Lot Size -------------_------------------------------ <br /> Water <br /> _____ _______________________Water Supply: Public System and name ---------------------------------------------------------- ---------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy LoamJ� Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ____ ------- If yes, type ---------------------------- <br /> (Plot <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 [ ] SEPTIC TANK'[ ] Size------------------------- ---------------------- Liquid Depth -------------------------- <br /> Capacity ------------- ------ Type -------------------- Material---------------------- No. Compartments ------ -------------. <br /> Distance to nearest: Well ____._____------------------------Foundation ---------------------- Prop. Line ------------ --------- VJ <br /> LEACHING LINE [ ) No. of Lines ------------------------ Length of each line---------------------------- Total Length -----------._____________.-_w <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------.---------------.....-_-� <br /> Distance to nearest: Well ------------------------ Foundation ----------- ------ ----- Property Line ________________------. -V <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ----------- ---- Number _.------ ------------------- Rock Filled Yes ❑ No CIO <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- 1 <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------,-.------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ________ ___________________________________ Date _____-______.__________________--) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------..-------------------------•- <br /> Disposal Field (Specify Requirements) -_ C _— - ----- _ ___ ___ ____ .__ _ ____ +rs�+___:.___________.___---_----- <br /> 11 <br /> ----------�-------- '�--"'-----�`------�'- � --------------------------------- <br /> ----------------------------------------------------------- --------I------ - ------------ --------------------------------------------- <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 /> BY ---------------------------- ------ r^ 7itle -/`�" ----------------------------- <br /> (if other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ----- --------------------------------------------- ------------------ DATE 3- l ----------------- <br /> BUILDINGPERMIT ISSUED ------------------ ---- ------------------------------------------------ ------------- -----DATE -- - - ----------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------ -------- ------------------------------------- ------------- ------------- <br /> ---------------------------------------------------------------------------- -------------------- I------------------------------------------------------------------------ ----------------------------- <br /> ----- --- -------------- = ------------ ----- ------ - ---------- <br /> Final Inspection by: / -----------------------------------------------------------Date -� '-- .... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />