Laserfiche WebLink
FOR OFFICE USE . —1 -,. APPLICATION FOR SANITATION PERMIT � <br /> Permit No. �Q--- - <br /> (Complete in Triplicate) <br /> ---------=-- --------------------- ---------------------- r�_c�__"`�'� <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 per to construct and install the work herein <br /> described. This application is made in complia ce with County Ordinance No. 549 and existing Rules and Regulations. <br /> V <br /> // ) I JJ, CENSUS TRACT _- - <br /> JOB ADDRESS/LOCATION .---- _!._y�_ -___ <br /> Owner's Name • � / --- ------ --- - ---- :---- ------ -----------.Phone - ag ~ J f <br /> Address -------------- -- - , `-- City ------- --------------------- ------- <br /> ---------------- ----------- ------------------------------ -- - - -- <br /> Contractor's Name ------License # -------- Phone <br /> Installation will serve. Residence TApartment House❑ Commercial :❑Trailer Court i❑ <br /> Motel ❑Other ------------ <br /> ------------- <br /> 2 ---- ---- - - <br /> Number of living units:------�--- Number-of'bedrooms -=5_7_:Garbage Grinder'-- `v_ L t Size <br /> --------------- <br /> Water Supply: Public System and Game - ------------------------�---- .----_.:�- -------- - .... <br /> -------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt{]J 14 _Clay (Ell eat F] Sandy.Loom -E] Clay Loam E]Hardpan E] Adobe Fill:Material ------ ---- if yes, type ---------------------------- <br /> R t S <br /> (Plot plan, showing size of lot, location of syst m in relation to wells, buildings;,etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic Ftank or seep g pit permitted`if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK [ ] Size------'�--------------- <br /> ------ Liquid Liquid Depth ----- 4 <br /> Capacity _�----------------- Type .----------- ---- Material- ;- _- _i_ No. Compartments <br /> Distance to nearest=Well ------------------------------------- f <br /> Foundation Prop. Line . <br /> LEACHING LINE [ ] No. of Lines1------------------------ Length of each line___l�-l-_-.---.------ Total Length ..-..-. -------------------- <br /> 1 t <br /> 'D' Box -------L--- Type Filter Material --------------------Depth Filter Material ---------------------------------..-•-____-- <br /> Distance to nearest: Well ------- -------------- Foundation* ------------------ Property Line ----------......----_--- <br /> SEEPAGE PIT [ ] Depth ----------I---------- Diameter --------------- Numbe; ---- --------------------- Rock Filled Yes E] No 0---- -----------------------------------------Rock <br /> Water Table Depth -- t <br /> Size -------------------------------- <br /> Distance to nearest: Well ---------- -----------------------------Foundation I------------------- Prop. Line -_-_---.__...-------__ <br /> REPAIRJADDITION(Prev. Sanitation Permit# --------------------- Date ------------ -------------------- <br /> Septic <br /> -_._._-- _-__-_-_-Se tic Tank (Specify Requirements)l---- <br /> Disposal Field (Specify Requirements) <br /> ) <br /> ----- - ---- ---------- ---- -- --- ----------------- <br /> ------------------------------------------------ ----------- --------------- D----- ---------— <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-Son,4.aaquin,LocaliHealth 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 lawi of California." <br /> Signed --------------------------------- ---------- `---'Owne <br /> BY -------------- --- 'Title -..= <br /> -- ------- - ---- ---------- ------------- <br /> (If other tha o nerl <br /> R itTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------- _ ------------------------------ DATE ------�"t `a- ------------- <br /> BUILDING PERMIT ISSUED -------- -- - -- ----- --------- ------------------------ <br /> — <br /> -------------------_-DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS - ------- - ----------- ---------------------------------------------------------------------------------------------------- ------- <br /> ---------------------------------------------------- - ----------- -- ------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------- -------------------- - - ------ ----- ----- - ----------------------------------------------------------------------------------------- -- - ------ ------- <br /> Final Inspection by: -------------- - -------- - ---`-�----- -------------- ---------------------------------------Date /_71=y <br /> SA A LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. M <br />