Laserfiche WebLink
FOR OFFICE USE: <br /> ----------- ------ <br /> � APPLICATION FOR SANITATION PERMIT . <br /> f [Complete in Triplicate) Permit No. _"7l _�_- _�_. <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> ------------------------------------ ---- ---------- <br /> f S7A- 24,02--t U <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described..ThisTgp.pl.ication..is,made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> n <br /> JOB ADDRESS/LOCA�N ___. __�.l�.--...a?,'_ __CENSUS TRACT --------------.___________ <br /> Owner's Name ------i-- 1� Phone <br /> ------- --- <br /> Address ------------------- f� �--------------- -------------------------------- City --'�----- -------------------------------------------- <br /> Contractor's Name - f License # Phone <br /> r�/ ` <br /> Cbz a -/- �-- -- - <br /> Installation will serve: Residence ❑Apartment House Commercial ❑Trailer Court <br /> Motel ❑Other -------- �- C:- <br /> Number of living units:---y-____- Number of bedroom SV <br /> Grinder ------------ Lot Size ____________________________________________ <br /> Water Supply: Public System and name ----------------------------------- ---------------- ------------- -------------------------------------------Private ❑ W <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt-E] Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ______-____ If yes, typ <br /> e ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 3 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size______� ��_�--______-_._ q p <br /> Li uid De th _ -_.?2-------------- <br /> Capacity --- ----- Type aterial� ----------- ---- /Compartments --- -%_--- -_-- <br /> Distance to nearest: Well _________ _______________________Foundation __ _____--_-___ Prop. Line ----- <br /> LEACHING LINE 7 No. of Lines --- /--------------- Length of. ach line____-__-,Zo_J------ Total Length __-.... ....... <br /> /f D' Box _ U_._ Type Filter MaterialU _____Depth Filter Material _ { __!-l_.______________________ <br /> Distance to nearest: Well -- ______________ Foundation ._ Q__ ______ Property Line <br /> SEEPAGE PIT 1j/j Depth ___: __ Diameter - ____. Numbe; ____ --__�_-__- Rock Filled Yes f�' No ❑ <br /> /+ Water Table Depth ----------- --------•------------------Rock Size --- 1A___?----------- <br /> Distance to nearest: Well ________________________Foundation Prop. Line -------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------••------------------------------•--------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------ ------------------------------------------.-------- --------------- <br /> --------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- <br /> ----------------------- ----- --------------------------------- - ---- <br /> - - - - ------------------------------------------------------------------------------------ <br /> (Draw existing 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 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 /> Signed -------- -- ----------------------------- - -------- ---- - -------------- Owner <br /> BY {/C1-./ --------- Title 1.�r_�7_ _.. (f1 <br /> [If other than own ) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ _____ DATE ----- <br /> ------------- <br /> ______ <br /> BUILDING PERMIT ISSUED ----- ------------------------------------ ----------------------------------------------- --------DATE <br /> ADDITIONALCOMMENTS -------- ----------------------------------------------------------------------------------- ---------------------------------------------1—---------------- <br /> -----------------------5= Vi <br /> ---------------------------------------------- <br /> ----------&--- ------------------------- -- <br /> ------------------------------- <br /> ------------------------------- �+{ - ---a-- --------------------------------- <br /> Final inspection by: �1 Date --- � --_� ------ -- <br /> SAN <br /> ---- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_ H_ 9 1-'AR Rev 5M ��- <br />