Laserfiche WebLink
FOR OFFICE Lrsl:: APPLICATION FOR SANITATION PERMIT <br />----•..................................................... <br /> lComplete In Triplicate) Permit Na.2I .......... . <br /> This Permit Expires t Year From Date Issued Date Issued ........... j <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/LOCATION ._��HO--..---- -- --------------- �.......�4?`'..................................CENSUS TRACT .......................... r <br /> Owner's Name 6-. .` ...........-..---- <br />" .. .. --- ------------------------------------------------------------ ............................Phone ....... <br /> Address ............ ............. ---------------------•--- ......... City -........................._............... .... ....... . <br /> ► ...license # ....... Phone <br />" Contractor's Name .,L%----- -----------'-----------�.-P--------•--------------�--------- ❑ ........_,-...... 0 -...-.._.....-...._.......---- <br /> Installation will serve: Residence A artment House Commercial Trailer Court <br /> Motel ❑Other........................... ............... 1 <br /> Number of living units:---I-------- Number of bedrooms .3.....-Garbage Grinder .. ..._ Lot Size ... ............................ <br /> Water Supply: Public System and name ------•----•--- ............ ------- -••-----....... -------------- .................. ...........Private <br /> Character of soil to a depth of 3 feet; Sand P9 Silt 0 rCCloy ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan❑ Adobe 0• Fill Material ............1f yes,type...........I... ............ <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 permittedif.public sewer is available within 200 feet,) ; <br /> [ ] SEPTIC TANK; j Size--- -----•-----•-----------•-- q P <br /> PACKAGE TREATMENT �� ......__.:. Liquid Depth ..._......:.:.:........ .. <br /> 1 , <br /> Capacity GO - Type . -. .. <br /> . .. ..�..... Material.Q**A?AL... No. Compartments ..............� <br /> Distance to nearest: Well --700. .................:.Foundation .A.0 Pro Lines..) .6 � <br /> LEACHING LINE [ j No. of Lines a.................... Length of each finegip--gs-gs-. Total Length .... <br /> F <br /> D' Box ---- _-_- <br /> -- Type Filter Material ...........!-------Depth Filter Material .............J._..--........ ......... <br /> Distance to:nearest: Well !-f _ Foundation ........................ Property Llne.�.---..". .....-•---..... <br /> SEEPAGE PIT [ j Depth ....... -------.---- Diameter ............. N R F. _........__........ Rock Filled Yes ❑ No ❑ <br /> t _ 1... . C <br /> Water Table Depth ---------------------------------•---f-....---Rock Size ------------------ ------------- <br /> I <br /> Distance to earest: Well .....:......................... .......Fou�clafiion _- rP op. tine ...................... I <br /> kEPAIR/ADDITION(Prev. Sanitation Permit# ------------ ------------------------- ---- pate ----------- ------ <br /> Septic Tank (Specify Requirements) _ ........ ..... ..... <br /> ------- ..... -..... <br /> _.. <br /> Disposal Field (Specify Requirements)� Ru.�_ '!! 4 !!`'.. -_ ____ <br /> n � r <br /> ] !± _ _ t •..._ •-•--•----•---- --- --•----••--- ............. .................................................I............... <br /> ----------------- -----------------•--------•---- ---------- - ............_........ ......................................... .....------•-• <br /> e Y certify prepared �--- .. . ..... .... <br /> (Draw existing and required addifion on reverse side) <br /> I hereb cern that I have re ared this and that the work will be done in accordance with San Joaquin s <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:Dlstdct. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I terrify that in the performance of the work for which this permit I Issued, I shall not employ any person in such manner <br /> as to beco sub' ct t ork n' Compensation laws of California:' ? <br /> f` Signed ------------------------------------------ Owner <br /> ByV----------- - --------------- • -------,---.-...------------------------------- le € <br /> ..-- ---------- ....--------------- ----....----------- --.... <br /> (if other than owner) <br /> • FOR DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED BY -_- --•_-.-- T --------------- DATE —_�.5.---- ----- <br /> BUILDING PERMIT ISSUED . . ^``..... <br /> .... - - -".....- DATE .... ..........y <br /> t... <br /> ADDITIONAL COMMENTS ---•----- <br /> --------------------------------- <br /> ....... <br /> .........,....-..--•-•-----•-------------------_--_---.-------------.--------.-.-...------..-----.._...-.._--.....---------------•------------------------------_- <br /> ----------------------------------- ---• -------•-----•.. ..........--•-••-----•---•.........-"--------•--.............------....... ..........----. ....................... ....--•- <br /> I - .. <br /> Final Inspection by: .. Date .........................:......•---•------- <br /> ..:... ............... <br /> 13 21s 1—E�r� v. 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />