Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT------- ---------- -------------- ----------- Permit No. _.7 Z'_ZJ_. <br /> (Complete in Triplicate) <br /> ------ ---- ------ F ( / 77/ <br /> Date Issued ___._"____:__.___. <br /> ------- --- --------------------- This Permit Expires 1 Year From Date Issued _ <br /> Application is hereby made to the Son Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is madelin compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _�/� ----- -l./---- -------- L���'`"' "�� --CENSUS TRACT ------u----•----------- <br /> y ' <br /> Owner's Name •- ----- -------------------------------------- Phone- <br /> Address ------------- a ..--3,3 ��.. City ------ - -- --- " <br /> Contractor's Name _ - - �----- --- ------ --- --- '` License # L - __ Phone ---------•-------------.....-- <br /> Installation will serve: Resi enc (Apartment House❑ Commercial :❑Trailer Court 0 <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-------I.__ Number of bedrooms -AY"_._.Garbage Grinder ----- ------ Lot Size ___ -----------•--- <br /> Water Supply: Public System and name ----------------------------------------------------------------------------------------•-----------•-•-------Private Al <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam] Clay Loam.D <br /> r <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,) <br /> PACKAGE TREATMENT SEPTIC TANK'[ j Size------------------------------------------------ Liquid. Depth -------------------------- V,t <br /> Capacity '--------------- Type Material---------- ----------- No. Compartments -------------•-------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------- -- -- Prop. Line -----------------_--- <br /> LEACHING LINE [ j No. of Lines- ----------------------- Length of each line---------------------------- Total Length ------------.---------------. �4`1` <br /> 'D' Box' ____1------ Type Filter Material --------------------Depth Filter Materia) ------------------------------------------•- <br /> Distance to nearest: Well _,_____________________ Foundation ------------------------ Property Line --______-____--.__._. - <br /> SEEPAGE PIT [ } Depth _r -_.:____---4.. Diameter '__= Number------___________________-___ Rock Filled Yes ❑ No ❑ <br /> Water/Table Depth ------------------------------------------------Rock- Size _________________-- <br /> Distance tolnearest: Well ----------------------------------------Foundation -------------------- Prop.-Line --------------------_ <br /> I � <br /> REPAIR/ADDITION(Prev. Sanitation+Permit# ---k---------------------------------------- Date ------••---------.-------------•--) �' I'D <br /> Septic Tank (Specify Requirements) �------ =- � �----------------- ------------------------------------------------------ <br /> I <br /> 1 <br /> is sal Field (S'pecify Requirements) ---------- ------ -------------- <br /> ------------------- <br /> --- --- -- - -- - <br /> "-�-�-- 1 ----- - -------------------------------------------- ---------------------- r <br /> (Draw existing and required addition on reverse side) r <br /> 1 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 ----------- -----I - --- --------------------------------------- Owner <br /> BY <br /> _ , ---�----- r - <br /> Title ---- ...----" ('t- ti =------ <br /> (If other than owner) i <br /> YOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ._ - - ----- ----------------------------------------------------------- DATE _._ `'j-�-~--�~-----------------.---- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------- -------DATE --------------- --------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------- -----------------=------------------------------------------------------------ --- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------ ------------ <br /> Final Inspection b <br /> f <br /> ____--------------------------------------- <br /> _____ __________________ _ _----------------------- <br /> _-------------- <br /> _-------------------------------------- <br /> __ _-- <br /> - --------------------------------------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />