72-507 - Laserfiche WebLink

Home Browse Search

take 'E " z a r FOR OFFICE USE: 2-f -app, APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ____________________________ This Permit Expires 1 Year From Date Issued Date Issued _-,_5-12-3� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ____c;?lY_f44A15 '—Af---_-_ ,_ __ __-_CENSUS TRACT . Owner's Name -�Dl+,Iow--- -------------------- - --------- ----------------- --- -------- ------------------Phone - _ 1 Address ------ o6v4U----/44.SS0-al) p----------------------------------- --- City--7#fA Contractor's Name ----------------------------------------------_-- _ -- _ - Licensed __TSFf�_ Phonecc , - ------ - Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other Number of living units:---- Number of bedrooms ----I.....Garbage Grinder ------------ _- Lot Size _ ------ Water Supply: Public System and name -----sx_k_G_-----------------------------------------------------------------------------------------Private ❑ �+ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;-� Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be. placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size_---------------------------------.----------- Liquid Depth __-_______---.-__--_. Capacity ------------------- Type -------------------- Material---------------------- No. Compartments --•---•-••----•.... - Distance to nearest: Well _-_-___________________________Foundation ---------------------- Prop. Line ..........._._..._... LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------- ................ "V 'D' Box ------------ Type Filter Material ____________________Depth Filter Materia( ._______.______.__._._.__.____..___.- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ........................ SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well __________________________._-----____--Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# _______________________________ ------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------------_ ____ ____ ___________________ T._____..-___._ _.___... Disposal Field (Specify Requirements) ____ .6.... C/�' 1/ ------ -b-{�!i�/� _ _•__ _-_- _- E--� -------------------------------------------------------------- -------------------------------------------------------------•------------ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in suc4 manner as to becomee}}s''ubjeec to Workma 's Compensation laws of California." Signed -- ------------------------------------------- Owner By --- -------------------- ------------------------------------------------------------------------------ Title __.------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED DATE ------__ _ _ __ _ _____________ BUILDING PERMIT ISSUED - DATE - ------ ADDITIONAL COMMENTS _.____ - -- - - --- - - - - -- -- --- -- Final Inspection by_ --------------------------_ `_____ Date ______ ___ _ ________ _____ �_ _._ _. �. SAN J ` Q LOCAL HEAL�W DI ICT E. H. 9 1-'68 Rev. 5M