Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- ---------- ----------------•----- - - -- ----- ------- <br /> (Complete in Triplicate) Permit No. <br /> ----------------- This Permit Expires i Year From Date Issued 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 /> -- ---------- 5---------------------- <br /> JOB ADDRESS/LOQ - ION 1dZ--� _ .._. ---- z�._---__- _CENSUS TRACT . \ <br /> Owner's Name _ . �t <br /> / ------------- Phone <br /> Address ..- <br /> K �— --------------- city . - -------------- ------------------------- <br /> Contractor's Name -- - ._. ate- ------.License # Phone ------------------------------ <br /> Installation will serve: Resince g[7:1 Apartment House,[:] Commercial ❑Trailer Court <br /> Motel ❑ Other --------- ksl. ± �'? r 1 - 0 <br /> Number of living units:--- .- Number of bedrooms .-----------Garbage Grinder Lot Size ------------------ - --------------------- <br /> Water Supply: Public System and name --------------------------------- ---------------------------------------------------------------------------Privatk. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •[ r, 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.) ,\ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 240 feet,) A� P <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth ----------- `.---.-------- <br /> Capacity -- .- ---------- Type --------- Material---------------------- No. Compartments ------- ------ <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <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 [ ] Depth -------------------- Diameter ---------------- Number --------.------------------- Rock Filled Yes ElNo <br /> Water Table Depth ------------------------------------------------Rock Size --------- --------------------- <br /> Distance to nearest: Well -------------------------------------- Foundation ----.--------------- Prop. Line ----------------..._-• <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------------------------------------------- --------------------------- -------------- ------- -------------------------------- <br /> Disposal <br /> -- <br /> - - -------------------- <br /> 0_7 Disposal Field (Specify Requirements) ..___ , __ #p.• .___ ___ -s. +-------------------------- <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 shalt not employ any person in such manner <br /> as to become subject to Workman's Com ensation laws of `California." <br /> Signed --- -------------------------------------- !.. . ----- Owner <br /> A.-t.U---------------------------------- <br /> BY t �_ i .Title <br /> . � <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ---------------------------------------------------------------. DATE -��" 3�ZI---------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------------- --------------- ---- - - ---------------DATE ------------------------------------------- <br /> - - - <br /> ADDITIONAL COMMENTS ----------------------------- ----- --------------------- <br /> -- ---------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------ --- --- - -------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ------ ----- ---•- <br /> --------------------------------------- ------ -- ---- ---- -- ---- ----- ---- ---- ----- <br /> Final Inspection by: �'1 �1.f� ----------------------------------------------------- ------------------- Date - .� '1� --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> E. H. 9 1-'68 Rev. 5M <br />