Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------ ---------- ------------------------ Permit No. <br /> (Complete in Triplicate) - •- <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> -------------------------------------------------------- <br /> -1 �---.- . / <br /> s <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 /> JOB ADDRESS/LO TION - ---- ---- -- 9 - CENSUS TRACT T-�. <br /> - <br /> - ------------Phone <br /> Owner's Name ------X111 <br /> Address 1 U -— ----- ----- City <br /> --- - - ----------- p <br /> Contractor's Name -- --License # 1 37Y Phone <br /> Installation will serve. Residence partment House�❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living-Units:—/------ Number of bedrooms ---/------Garbage Grinder ------------ Lot Size -----_----------- ------------------------- <br /> Water Supply: Public System and name ---------------------- -------------------------- -----------•----------------------------------------------•-Private [J <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay. eat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ----------- if yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) V <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEP7fC T NIC;[ ] Size------------------------------------------------ Liquid Depth --------------------------- <br /> Capacity ---- -- ----------- Type --- ---------------- Material---------------------- No. Compartments ------------.....: <br /> Distance to nearest: Well ------------------------------------Foundation ____._--------------. Prop. Line -----------.---------- V <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 --------------------=--- Foundation ------------------------ Property Line _------..---.-.-.._.- <br /> SEEPAGE PIT [ j Depth -------------------- Diameter ---------------- Number ----,-.---------______----- Rock Filled Yes [] No i❑ <br /> �T <br /> WaterTable Depth -----------------------------I-------------------Rock Size -------------------------------- NA <br /> Distance to nearest: Well ------ ----------------------------Foundation --------------- ---- Prop. Line ------_------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank {Specify Requirements) -------------------------_-- ----------.:� -- - •----- ------- <br /> Disposal Field (Specify�RReeVremennts) ---``ry`�'� - --------- ----------------- <br /> J <br /> ----------------- <br /> ls- <br /> -----------x- - 1 - -- �'----------- ---- ---------------------- ---------------------------------------------------------- <br /> ---------------- I--------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <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 -------------- ----------- �-qo� <br /> - - ----- -'Owner Title ---- d . <br /> ------------------------------ <br /> (I other than owner) <br /> POR ZEPARTMENT USE ONLY <br /> Of. OF <br /> APPLICATION ACCEPTED BY ------------------------------------------ ------------------ DATE --- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------- ---DATE ------------- ----•------------------------ <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------- --------- <br /> --------------- ------------------------------------------- --------- <br /> Final Inspection by: <br /> --------- ---------------------Date��Y----------��----------- - ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />