75-53 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...................... (Complete in Triplicate) Permit No. ... ......... ....................... s --••-••••••••••••••-•---•---••••••.•••-•................. � This Permit Exp ices 1 Year From Date issued Date Issued .., 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 complian with County Ordinance No, 544 and existing Rules and Regulations. JOB ADDRESS/LOC .-.._.... .. ... .. .. ...................................CENSUS TRAGI Owner's Name .. &':"�-�.�......_. .� . _ - . _... ...:. . .��. ... _ ..._. .'.. ..::.......Phone .................................... Address ........... ..... City Y...:...................................... 1� A Contractor's Name ..... .. ...-. .�......................................License # Phone ..... .............................. Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑Other ......:..........................:...:...... Number of living units,..--.....J Number of bedrooms ..._- .-Garbage,Grinder ----- ...... lot Size ...................................... ..................... Water Supply: Public System and name ..................... ---.Private Character of soil to a depth of 3 feet,1 Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loom ❑ l ardpon ❑ 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 ... Material...................... No. Compartments ... .............:.... �[ I Distance to, nearest, Well ..Foundation ....:......... Prop, Line � •--• ...................... LEACHING LINE No. of Line .. Length of each line............................ Total length 'D' Box ......J.... Type Filter Material __Depth Filter Material .................... Distance to nearest, Well ........................ Foundation ........................ Property Line ........................d� SEEPAGE PIT O Depth ....... .......... Diameter ...... Rock Filled Yes ❑ No C3P ......--•--..... Number ............................ Water Table,:Depth .............Rock Size , Distance to nearest; Well ........................................Foundation ..._..... .......... Prop. line ............-......... REPAIR/ADDITION(Prey. Son itotion'Permit# ...................... 10 . Date ...:.............................. ) Septic Tank (Specify Requirements]".................... ....------ ........... ,.. ........_._...--•---... -......... •......... _......... ..... Disposal Field Specify Requirements)p p encs) .' •• M ...................................................................................... ... (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. Horne owner or licen- sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit Is Issued, I shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed ......................................... ..................... Owner 5 By ............ ........--•.............. ,! ',.... .. xlt{e .... ""► (If other than owner) 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -: ..........., DATE ......� .�.../.. .. .�........::. BUILDING PERMIT ISSUED } DATE ..........................•-•--...--------:..................--•---......4........ .....:..................................... ADDITIONAL COMMENTS ..............:...4..................... ........:... - .............. .......-•..........................1... ..................t......_.............................................. ..:..........--•-----•-•-----.............................:.................. ........... Finalinspection...................................................... ...........I... . .......................................-................................... .•.....---.. Y ..... ...................Date ...C.: /. _. ............ SAN JOAQUIN LOCALHEALTH DISTRICT I E. m.13 24 1.'68 Rev. 5M 7179