Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ?� <br /> Per Na. ...7�' � <br /> s <br /> .................. <br /> (Complete in Triplicate) <br /> ............................................... <br /> Date issued <br /> This Permit Expires I Year From Date Issued j <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 /> e s <br /> JOB ADDRESS%LOCATION ... `I l._./ZWRAV"'W........-°:........................... ................CENSUS TRACT .?/ ......--•......... <br /> Owner's Name ... � ` t.._.... . /� � ..........................................................................Phone..................................... <br /> Address ....-A-57 <br /> ...-_ —1?-41 _... .........................................................• Cityll�......------......................._..... <br /> Contractor's Name License # rsl -' Phone k •-•- <br /> = ------••-•• <br /> Installation will serve: Residence P Apartment House 0 Commercial❑Trailer Court C3 <br /> -I <br /> Motel ❑Other --------------- -----------•................ <br /> Number of living units:____..._. Number of bedrooms .......Garbage Grinder ! ! '. Lot Size ¢ ?A - a_... ....--••••-•••, i <br /> Water Supply: Public System and name ...................-...........................................................................................Private, <br /> Character of soil to a depth of 3 feet: Sand El .Silt ElClay ❑ -Peat❑ Sandy Loam 0Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ........__-. If yes,type ---------------------------- <br /> (Plot pian, showing .size of lot, location ofsystem 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,) 1 <br /> PACKAGE TREATMENT { ] SEPTIC TANK f ] Size................................................ Liquid Depth .......................... i <br /> Capacity .................... Type _.._..---•--. ------ Material...................... No. Compartments ...................... <br /> _ , <br /> Distance to nearest: Well .......................-............Foundation ...................... Prop. Line ................. 6- <br /> LEACHING-UNE .' [ ] 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 __.__._-._.-_- ......... 1 <br /> SEEPAGE PIT ( ] Depth ----------- Diameter ................ Number ..................._......... Rock Filled Y.es.❑ -No ❑9 j <br /> Water Table Depth -------Rock Size <br /> Distance to nearest: Well ........................................Foundation ..................... Prop. Line ......................9► <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ................ ........................... Dote .................................. <br /> SepticTank (Specify Requirements) ................•--�.,-/- .........------•-- -------�-----04................... ................................................................ <br /> Disposal Field (Specify Requirements) ... 1: af _ <br /> -------- re f . `hG t Rte` �-.......................................................................................................•---•-----__--------....... <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 Son 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 _Ci '_. � j -......._.._._..-----------._........ <br /> (if oth than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .......:-� -- -• ...........................•- • --...--•---... DATE rY._.?.. <br /> � -_---------- <br /> BUILDING PERMIT ISSUED _.._....'----------------------------------------- <br /> --------------------------- <br /> -----........................_DATE ._-........................................ <br /> ADDITIONALCOMMENTS .........................................................................................--................-.................................. ................ <br /> .....................................-............•--•-••-:.: _:.......................---.................................................I.......... ...................... <br /> -- -•-----.._ <br /> - ___- ----•....... <br /> Final Inspection by: .... ...................... ................ <br /> Date .. .�' _ <br />'I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 71723M <br />