Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -/ / <br /> - <br /> --------------------- --------- ------------- ---- {Complete in Triplicate} Permit No. -. �� - <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> --- ----------------------------------------------------- <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 ---- -- --- sem ----CENSUS TRACT -------------------------- <br /> Owner's Name Q _�-----------27 C?_ _ !/------------------- -=----------- ------Phone ---------------------- -------- <br /> Address --------------/U L7.3/f- -- City <br /> Contractor's Name ----------------- 4L� I- --- <br /> License # Phone <br /> Installation will serve: Residence partment House,E] Commercial ❑Trailer Court ',❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units;------------ Number of bedrooms ------------Garba_ge Grinder ----- ------ Lot Size ---____--________--______________________ <br /> Water Supply: Public System and name ------------- -•------------------ --------- ------------------------•---------------------- ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------- <br /> ---------- Liquid Depth -------------------------- <br /> d <br /> CapdcitY -------------------- Type --------------------- Material---------------------- No. Compartments ------•-----------•--- W <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---.----------.------- 9 <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length ---------------------------- \1% <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 ❑ No 0 <br /> Water Table Depth------ `---------------------------- --Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) S <br /> Septic Tank (Specify Requirements) ---------------- ------- --------- --------------------- ^ - -- ---------------------------- <br /> Disposal Field (Specify Requirements) ___-_____ -----i --------- <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 ------------------------------------------------------------------------------------------------------- Title _ --------------------------- -------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ _ --°-- ---.___-- ------------ --------------------- <br /> ----------------------------- DATE -------------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> ------------ --------------------------------------------------------------------------------------------------------------------------••------- --------------------------------------------------------- <br /> -------------------------------------------- -------y----------------------------------------- <br /> Final Inspection by: _____________ _____���______ <br /> ------- ---------------Date .tr:%��--------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />