Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- (Complete in Triplicate) Permit No.. __ ___ _____------ <br /> ----------•-------- -----------------=------------------- <br /> _ _-________________-________-__________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued .- '_�� <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 ADDRESSAOCATIONN -------� ��/ -- 5---t---- W ---------------CENSUS TRACT ---------------_- ....... <br /> Owner's Name 1� Q- 7 Phone <br /> ----------------------------------- _----_ ------- <br /> ,q <br /> -•---- 1 <br /> Address --.�. � ------- - City l�!Y _ ------ -------------------------------- <br /> Contractor's <br /> -- - -- --- <br /> p� {- _ <br /> Contractor's Name ---__- �- <--------- ---------- <br /> -_.` --------------------------------License - �0-____ Phone p--1 _ <br /> Installation will serve: Residence ❑Apartment House ❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--/--- <br /> Number of bedrooms __3------Garbage 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 LoamF-] <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <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,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size----- --/d <br /> -------------------------- ------------ Liquid Depth --------------------­--- <br /> Capacity <br /> -_----------------- --- <br /> Ca acit ------- Type ------------------- Material-------------- ------- No. Compartments ------.------_------ <br /> p Y ------------- Yp P <br /> Distance to nearest: Well ----------------- ---------------Found ion ---------------------- Prop. Line ---.---------------- <br /> LEACHING LINE [ ] No. of Lines ________________________ Length f each line-------- -___.______.______ Total Length .__:__-_____-____-_--....__ <br /> 'D' Box ------------ Type Filter Materi --------------------De h Filter Material -------------------.._.--_..._.-----._----.- <br /> Distance to nearest: Well _-_________ ___________ Foundatio __------- Property Line --------- -------------- <br /> SEEPAGE PIT [ ] Depth _____-_________-__ Diameter ______________ Number _:__________-__-__________ Rock Filled Yes ❑ No C. } <br /> Water Table Depth ock Size . <br /> Distance to nearest: Well --__-- ------------------------- ---Foundation 4 <br /> Prop. tine _... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___________ __________ - __ Date _-__-_.___________________________) <br /> Septic Tank (Specify Requirements) --------------------- - -------------- --------- •------------------------ -- # <br /> Disposal Field (Specify Re uiremenfis). __ / % ---- ----97�� - <br /> ���1� 1 ea /----- c --- 1 Y---------------------------------- - <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 subie t to W rkman's Compensation laws of California." <br /> Signed ---- -- ----------------------- --- -------------------------------------- Owner <br /> ----------------- <br /> By --:---- ------ -- ---- ----- ------------ Title ---------------- <br /> ---- - ------------------------ <br /> - --------------------------------------- --- <br /> (If other than own <br /> FOR DEPARTMENT USE ONLY <br /> " <br /> APPLICATION ACCEPTED BY -------- -- -- - ----- - --- �---------------- ------------------------------------ DATE -----'--------------------------- ..._..------ � <br /> BUILDING PERMIT ISSUED -------------------------- -------DATE -_-----------.-------------------- <br /> --------- - ---------------------------------------------------------- <br /> ADDITIONAL COMMENTS --------- -------- -------------------- -------------------------------------------- <br /> - ------------------ <br /> -------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------ ---- -----I--------------------------------------------------------------------------------------------------------------------------------------------- ----------------------- <br /> ----------------------------------------------- -- ---------------------------- --------_---------------------------------- ----- <br /> Final Inspection by: -------------- e ------'f'`---------------------------------- --Date ---�-- -' 4-.---- - <br /> �,�- --------------------- <br /> " '' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M "Z) r <br />