Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR ANITATION PERMIT <br /> -------------------- Permit No. --- 3-L 6 <br /> -------------- <br /> (Complete in Triplicate) <br /> -----------------------_-_------.-----__--____ ___----- This Permit Expires ]`Year From date Issued Date Issued <br /> Application is her eby 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 <br /> and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT O --CENSUS TRACT -------------------------- <br /> Owner's Name - ,------- - _-- ---- Phone ------------------------------ <br /> Address ' ------ �I,- -��-�-- Ci ---------------------------------------------- <br /> Contractor's Name e .License # -�Q. y Phone ------------------------------ <br /> Installation will serve: Residen a [ Apartment House,❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----- Number of bedrooms __>'__Garbage Grinder ------- Lot Size _--_0_4 --- - 1 <br /> Water Supply: Public System and name -------------------------------•--------------------------------------- ------------------- -------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ :. Clay ❑ Peat❑ Sandy Loam"N Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes{type ____________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells,-builclings,"etd, must be placed on reverse side.) <br /> } <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) LN <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size-------------------______--------------L-------- Liquid Depth _____---___________._-_ W <br /> r " <br /> ,. Capacity ------------ --- - Type -------------------- Material--------------------- No. Compartments - ----•--------------- <br /> t Distance to nearest: Well ------------------------------------Foundation -_____'____ Prop. Line ---------------------- <br /> LEACHING <br /> ___-______--_-_-_ .LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-----------_----------------- Total Length --------------------..__._.-- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----_--------------------..--.--------...... <br /> I <br /> k Distance to nearest: Well _______________________ Foundation ---------------------.__ Property Line _-_____________ ....... <br /> d <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ----------- ---- Number, __ -----------------------. Rock Filled Yes ❑ No ❑ <br /> Wafter Table Depth ------------------------------------------------Rock Size ---------------------------•---- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line _-..------------.--_.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------I <br /> Septic;Tank (Specify Requirements) ------------------- -- -------- - -- -------- ,�- ----- ------------------------- --------------------------- <br /> ,D.i,sposj,a�l Feld (S-p- -c-ifR urema-ts)y � .. y <br /> ---------- ----- --------------------------------------- - <br /> ----------------- <br /> - -- --------------------- - --------- --------------------------- ------------------------------- <br /> -------------- <br /> (Draw exist--g 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 San Joaquin Local Health District. Home owner or €icen. <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 /> Signed ----------------------------------- --- <br /> --- Owner <br /> +Uf Title -- ----------------------- . <br /> (If other than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ 0---—--------------------------------------------------------- DATE --� --7 " 73"=----••--- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE -- -------------------------------------- <br /> ADDITIONALCOMMENTS --- -------------------------------------------------------------------------------- ------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- <br /> ------------ ------ ------ ----- ------ -------------------------------------------------------------------------- -------------------- <br /> ------------------- --- --- ---------------------------------- ------------------------------ <br /> FinalInspection by: ---- ------ ---------------------------------------------------------Date ---- ----- = --.------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />