Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ---- --------------------------------- ----------- (Complete in Triplicate) <br />--- ------- --------------------------------------` Date Issued __ ----Z---7 Z <br /> 1I' This Permit Expires 1 Year From Date Issued <br /> - <br /> 11 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal! the work herein <br /> described. This application is' made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> = -----CENSUS TRACT -------------- ------•---- <br /> JOB ADDRESS/LOCATION ---------------------------------? <br /> " <br /> Owner's Name ---C�li�-���------- f�t'--P fL'-_.�----- ------------••--------------------- --------- -.- - <br /> -----Phone a ------- <br /> --- I _U_S!L__ ----.. City ,Gyp TJI ------------------------------------------------- <br /> L fT <br /> Address . �' /�/ o <br /> 9 <br /> ---License / --- Phone -- �-------- <br /> Confiractor's Name -- - ,-/�------ �`�- /��--------------------------------- -���------� <br /> Installation will serve: Residence [Apartment House'❑ Commercial :❑Trai.ler Court ❑ <br /> Motel ❑Other -----,---- --------------------------------- <br /> Number of living"Onits.-------�. _ Number of bedrooms ___,3__-_Garbage Grinder __-_._______ Lot Size ___E ------------------••--- <br /> Water Supply: Public System and name ___--___________--___ _ _ -__ Private <br /> Character of soil to a depth of 3 feet: Sand'Ve Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> 11 <br /> Hardpan ❑ Adobe ,F1 Fill Material ------------ If yes, type ---------------------------- <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 flank or seepage pit permitted if public sewer is available within 200 feet,) ` <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ ] Size---- -----------------/ize <br /> ----- ----- ---- Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material---- --------- No. Compartments O� <br /> :I: 1 <br /> Distance to nearest: Well ------------ -- Foion -_ -____-__- Prop. Line -----.____---___-.____ <br /> LEACHING LINE [ j Nol� of Lines --------- -------------- Length o each line---- -- ------- -- Total Length -------------------------• <br /> Depthi er Material <br /> D' Box ---- ------- Type Filter Material ----------------- ------ ----•--------•------------------•---- <br /> Distance to nearest: Well ---------------- ------- Foundatio ------------------ Property Line ------------------•-•--- <br /> SEEPAGE PIT [ ] Depth - Diameter _____ __________ Number - ___._________ Rock Filled Yes ❑ No ❑ <br /> ------------------- <br /> Water Table Depth ---------- ------------- -------Roe ----------------------- ----•--- <br /> ---------- - <br /> Foon Prop. LineDistance to nearest: Well ___________ _________ -------IDat ---- j <br /> --------- <br /> REPAIR/ADDITION(Prev. 5d nation Permit# ------� ------------- - <br /> IM.. <br /> Septic Tank (Specify Requirements) ------------------- -------------------------------- <br /> 4 -------APe----- <br /> Disposal <br /> ---------- --- --------- <br /> Disposa! Field (Specify Requirements) - "`' -------APe---- <br /> -- -s <br /> i ---------------------------------- <br /> ----------------- <br /> ,,te�rr - ------------ ------- - - <br /> _l� _1 ----------.-�� r ------- <br /> 11 <br />` --------------------------------------------------------=------------- - <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I hall 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 /> - ` Y <br /> Signed ------ I --------------------- t---- - Owner �. <br /> ------------ Title ----------------------- <br /> (If other tha:F owner) .� <br /> EE F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 6Y ----.-- Viae-- ----- ---------------------------------------- DATE ----- <br /> -------=- --- --------------- - <br /> BUILDINGPERMIT ISSUED---- --------------------------- --------------------------------------------------- ---DATE ----------------------------------------- - <br /> ADDITIONALCOMMENTSI.- - -- -- - -------------------------------------------------------------------------------------------------------------=-------------------------- <br /> i ---------- ------------------------ -------------- -------- <br /> ------�---------------------- <br /> ---------------------------------- <br /> --------------------------------------------- <br /> -------------------------- <br /> � -------------------- - --------- ------- <br /> �� <br /> ° <br /> Date <br /> Final Inspection by-- ----------: -------- <br /> SAN --,/`- ` <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1•'68 Rev. 5M' , <br />