72-543 - Laserfiche WebLink

Home Browse Search

' FOR OFFICE-USE: APPLICATION FOR SANITATION-PERMIT ---------- ----- --------------------- XSan (Complete in Triplicate) Permit No.---------- ------------------`--J-- ---------- -- ------------------- ThisPermit Expires 1 Year fromDate Issued Date Issued -�Applicationis-hereby made to theaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with unty Ordinance No. 549 and existing Rules and Regulations: a �y JOB ADDRESS/LOCATION .___ . �___ : :--�'c'` ` -•--- ' `"'"` '--�----CENSUS TRACT ____----_- --- Owner's-Name _.__� _'j�=------ �1 �„' R -------------------------------- ----------- -------Phonev c� �� Address ! + --`----- -- ` J City �'.Cx ' -------- .�,,��. Contractor's Name ------- ;-_ ___ _-- -----------------License # - 7-fv-r.� rj-- Phone SY_ Installation will serve: Residence ,*Apartment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- y Number of living units.-./----- Number of bedrooms __ � r5�r-�L ----------- .____Garbage Grinder ___ __ _____ Lot Size ____ _______ _ Water Supply: Public System and name ________,__ _ &,) - - - ------- --------- A-Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat 0 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.) [p� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) � r 'C3 PACKAGE TREATMENT { ] SEPTIC TANK -------- Liquid Depth ____A------------- Material Type/-e-"---- _-_ ---4 No. Compartments -- _____.._f__.. Distance to nearest: Well __._4 _ ---------------------Foundation _ Q____ _______ Prop. Line _____ ____._.... LEACHING LINE l- No, of Lines ______-�_______;_--__ Length of each line__,_~-reATotal Length .�"-��0 �,; 'D' Box ____/____ Type Filter Material _� ------Depth Filter Material __- 9_---______-_-__________ ________ Distance to nearest: Well _.__ �'_--_---_WNumber Foundation _.,lG....._......... Property Line _____�z... .......... Depth --e- r ------------ Diamete '=�` ---------P_------'�______ Rock Filled Yes E' No 01- z Water Table Depth -----s ZG"---------------- ------ --------Rock Size ----�=K--- --'---------------- Distance to nearest: Well -----/40-_e"/-------------------Foundation _i "_ _____ Prop. Line --�-S .......� i REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________________ Date -------------------_______________) Septic Tank (Specify Requirements) -------------------- ----------------------------------------- -------------------- ---------------------------_------------------•---------- Disposal Field (Specify Requirements) --------------•------------------------------------------------------------------------------------;--------------------------------- f ------------------------ ------------------ ---------------------- (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 such manner as to become subject to Workman's Compensation laws of California." Signed ----------- --------------- - ------ ------------------�--------------- --------------------. Owner BY ......9` - ----- -------------------- Title -------- -------------------------- Y (If other than owner) �• �,3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ ------- ------ ------------------ ------------------------------------ DATE --------- BUILDING PERMIT ISSUED __--- DATE -_- - -- ----- ------------------ ------ --- ADDITIONAL COMMENTS - Ci�[+✓� - - !✓---- ---- "� �.....-r J`d �------- ---- � �r--� �"u----- ------------------------------ - ------------ --------- --------------------------------------------------------- ------ -------------- -- - ------------------------------------ ------- - -- - --------------- -- ---------------------------------------------------------- ---- -- ---------- Final Inspection by: - Date --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M