Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> i ___________ ___ ���_/ _._� Vii],/ This Permit Expires lE Year From pate Issued <br /> Date Issued _3_71.7_7.?— <br /> r 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 /> JOB ADDRESS/LOCATION . 3- ---------------------------------------------- --CENSUS TRACT ----------------------_ <br /> Owner's Name ? r------------------------------------------------------------ -Phone ------------------------------ <br /> Address ......... <br /> ----------------------- <br /> Address ... ` <br /> = OY-------- Cit ------•--•----------------- <br /> Contractor's Name -------- <br /> -- --- ----- ---- '----5-+�" -------------------License # 6 ---- Phone - <br /> r - <br /> Installation will serve: i"Residerice❑Apartmentj-louseCommercial ❑Trailer Court <br /> # t <br /> + Motel E] Other ---V, -------- ------------------ <br /> Number of living units:___y_ Number ofi.bedrooms ----J�-----Garbc a Grindert_._: ____ Lot Size ----- <br /> Lot <br /> Water Supply: Public System.and name -----------I-- ---------t.......----------- i --- ---------- --------Private F-1t <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ i Clay 0_Peaf n_-Sandy Loam-n Clay Loam ❑" <br /> I Hardpan ❑ Adobe Fill Material ------------ If yes, type ---------------------------- <br /> IW <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) t.r <br /> f <br /> NEW INSTALLATION: (No septic tank or seepage.pit,Rermitted-if public sewer is available within 200 feet,) Lei <br /> PACKAGE TREATMENT [ ]. °SEPTIC TANK:[ ] Size---�------------------------------ --- -.>` ,Liquid Depth -----_---------------._-_-- Cr <br /> Capacity ------- ------ Type --------------------Material-------"�_ ,:No. Compartments --------- <br /> ------------ <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ______________--__---- <br /> f <br /> LEACHING LINE [ ] No. of Lines _______________________ Length of each line---___'____.____._._____ Total Length ----------------------------- <br /> 'D' Box -- Type Filter Material ____________________Depth Filter Material _------------------_____________._______ <br /> Distance to nearest: Well ____________________' Fo-uttdation— Property Line. -4________________._ <br /> SEEPAGE PIT [ ] DeptEi _--____`µ..Diameter ___________r-_. Number ___ Rock Filled Yes ❑ No ] <br /> } , <br /> Water Table Depth ------------------------------=-----------------Rock Size i------------------------------- <br /> Distance to nearest: Well ______________________ _________________Foundation ---------------.----,Prop., Line ---•___-__---_._--___- <br /> REPAIR./ADDITION(Prev. Sanitation Permit 1# -------------------------------------------- <br /> ,I Date ---------------------------------- <br /> Septic <br /> -------------------------------Se tic Tank (Specify Requirements) -------------- - --'- - - ----:--)-----.:---;-------,-bi-�t-,------------------- <br /> D <br /> - <br /> ----------------. <br /> osal <br /> Dspements) -74 ------ ---- --------- ------------=----------•----------.- <br /> _ , <br /> ---- ------ <br /> (Draw existing and required addition.on reverse side) I <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 Lows, 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 shallf not employ any person in such manner <br /> as to become subject to Workinan.s Compensation laws of California.' <br /> F <br /> Signed = ' j <br /> —Own <br /> er-- - ---------------------------- <br /> By <br /> ------- --- <br /> By ------------------ ---- ----- -------------- Title _.. _._. ----- -- - ---------y <br /> --------- <br /> (If other ner). <br /> FOR DEPARTMENT USE ONLY f <br /> APPLICATION ACCEPTED BY -------rte -_------- <br /> _ j* J <br /> Cl c N: -=--- ---------�--------------------- DATE _ 7 J - -�-- <br /> BUILDING PERMIT ISSUED --------------------------------------------------- `��' =- DATE -------- <br /> -------- <br /> ADDITIONAL COMMENTS -`---------------------------------------•------------------------------------------------------------------------------------------- --- ---------- <br /> ---------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------�7�� <br /> ---------- <br /> --------------------------------- <br /> -- - - - - <br /> 1 <br /> -------------------------------- --- --- ---- -------------------------------- <br /> ----------------------------------------------------------- ----f - <br /> Final Inspection by: - ------------------------------------------------.Date =* ` /—� <br /> SAN J AQUIN LOCAL HEALTH DISTRICT [ �/ <br /> r <br /> E. H. 9 1-'68 Rev. 5M <br />