Laserfiche WebLink
r-C 1Mi <br /> APPLICATION FOR SANITATION PERMIT 1-'7 <br /> FOR�OFFIC USE: i� Permit No. <br /> -------- <br /> �'" (Complete in Triplicate) <br /> ---------- fir/ Date Issued -" � <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby 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 and existing Rules and Regulations: <br /> /'- -HCl- 1 �' CENSUS TRACT <br /> JOB ADDRESS/LOCATION - ---- :-- Phone ------------------ <br /> Owner`s Name _ _ ----..- <br /> - <br /> -----. City . f� <br /> Address _._S -���f �� �_ ' <br /> 01 <br /> !G' } / License #�� d�" Phone <br /> Contractor's Name _.___ -- _ {� <br /> G ---------------------- <br /> r Installation will serve: Resid�partment House Commercial Trailer Court ❑ <br /> S <br /> Motel ❑ Other ---------------------------------- --- <br /> Garbage Grinder - .-- _---_ <br /> Lot Size <br /> Number of living units:--- ---- Number of bedrooms. _ private ] <br /> Water Supply: Public System an name -------------------------------•------- ------------ ------- <br /> Cla Loam <br /> Character of soil to a depth of 3 feet: Sand'[] ❑` Silt <br /> Clay F-1Peat[:1 Sandy Loam [I Clay ❑ <br /> Hardpan r-1 Adobe Fili Material ------------ Y-_--- If es,type ------------------ --------- <br /> location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> (Plot plan, showing size of lot,,. <br /> 200 feet,) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within <br /> Liquid Depth A <br /> PACKAGE TREATMENT [ ] Size_ 97 --- 'i <br /> SEPTIC TANK'[!�]� Size-XX - �- <br /> T 10' - Materialep No. Compartments ____-_--. <br /> Capacity� --� '- Type/10" <br /> s <br /> Foundation --� ------ Prop. Line --�----•--•---•- <br /> Distance to nearest: Well - � -- ------------• s• <br /> r�� Length o each line __ Total Length ��.� --------------- <br /> LEACHING LINE V No. of Lines ---�-------- ----- g AP <br /> J ,�j �' _De th Filter Material ----------- ---------------------•- <br /> Filter Mafienal r - - - ---• P <br /> `D' Box , IV--- TypeY <br /> er Line -- �--------------- <br /> Distance to nearest: Well -- --- „- Foundation ./ ------- Property <br /> f _--"__. Number __/------ Rock Filled Yes, ' No 0 <br /> SEEPAGE PIT Depth _ hrr__------ Diamefieri <br /> ------Rock Size - -- ----------------- <br /> Water Table Depth - -- = ----0---------`-------•- <br /> Distance to nearest: Well __-_����-- ---- <br /> I --------------Foundation --- P--------- Prop. Line _ --------- <br /> ---- <br /> • -- - <br /> Date ---- -------------•---•----------- <br /> REPAIR/ADDITION[Prev. Sanitation Permit# -------------------------- <br /> ----- ------- <br /> i ----------------------------- -------------------- ------------ <br /> ------------------------ --•�----------------------------- <br /> Septic Tank )Specify Requirements} ___-___._-__"------------------------------ <br /> ------------------------- <br /> Disposal Field {specify Requirements) --------------------------------------------- <br /> -------------- <br /> 4 <br /> ---------------- ----- --------------------— - -------- ---- - <br /> {Draw existing and required addition on reverse si d e <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. Nome 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." s <br /> t <br /> Owner <br /> Signed -------- - - ---- -------- ------------------- --------- <br /> --- ---------------- -- ---- -- ---- <br /> Title - ----.-- ------------------ <br /> - 1 -------- ----------- <br /> -- <br /> - ----------- <br /> By ------------ --- <br /> f other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE ---- -- -----------------7­ ------- <br /> APPLICATION <br /> -- ------ <br /> APPLICATION ACCEPTED BY --- ---- ------- -- -- <br /> ----------------- -------- ------- --DATE ---- ---------------------------------------------- <br /> - <br /> BUILDING <br /> --- ------ <br /> BUILDING PERMIT ISSU --- ------ ------- -------- -------- ---- ---- -------- - <br /> ADDITIONAL COMMENTS -------------------------- - -------- <br /> --------------------------------------------------------------------7---------------------------------------------------------------------------------------------------------------------------------------- <br /> --------- ---------------------- ---- --------------------------------1---- <br /> _ __ _ --------------------------------------------------------/ -------- <br /> - -- -- - -- --- - -- Date � f <br /> Final Inspection b - - �'"•�'` <br /> p y• - <br /> -- - -- -- - --- <br /> SAN JOA UlN LOCAL HEALTH . DISTRICT <br /> F H 9 1-'6B Rev. 5M <br />