Laserfiche WebLink
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
FOR OFFICE USE: A - APPLICATION FOR SANITATION PERMIT <br /> ----- - - --------- ---------------------------- ---- Permit No. <br /> (Complete in Triplicate) . <br /> This Permit Expires 1 Year From bate Issued Date Issued <br /> _ _- -6 <br /> ---------- --------------------------------------__ <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 w' h Col y Ordinance No. 549 and existing Rules and Regulations: <br /> �` <br /> JOB ADDRESS/LOCATION ._ ur .,% ` l! <v -----CENSUS TRACT -------- ------------ <br /> Owner's Name --. /, - -- ------------------------------- --- ------- ----------Phone - ---------------------------------- <br /> Address -------- -------- --- - -•-- City ------I_rLl}IVT�C-f}----------------------------------------- <br /> - - <br /> Contractor's Name ----- ----- -- -- - - --- <br /> ---------------------------License # ------ Phone <br /> Installation will serve: Residence 2�<Partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ---------------------------- --------------- <br /> Number of living units:----I------- Number of bedrooms ---__Garbage Grinder Esc?____ Lot Size T0_Y_____ <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 _/V - 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.[ ] Size------------------------------------------------ Liquid Depth ---:-----------------.:---- <br /> Capacity -------------------- Type -------------------- Material----------- No. Compartments ------ --------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------_---:----------- �l <br /> LEACHING LINE [ ] No. of Lines ____________________ Length of each line____________________________ Total Length .---_______-____--.____-____ <br /> 'D' Box ----- -.- Type Filter Material ____________________Depth Filter Material ------------------------------------------- <br /> Distance <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 ----------------------------------I <br /> Septic Tank (Specify Requirements) ---------------------------------------------- - --------------------------- <br /> Disposal Field (Specify Requirements) __ __U S-- ----Co- -_�a_- --- ----- -------------- <br /> --- ---------- -- <br /> ---------------- ----------------------- <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 /> ------ ------------------------------------------- <br /> BY --------------- Title ------------------- --------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT US ONLY <br /> APPLICATION ACCEPTED BY _.______r -____-_ c_-� =-+ ------- -- DATE ------ �"- ..'- ------- - <br /> ------------------------------- <br /> BUILDING PERMIT ISSUED ---------------------------------- ----------------------------- ---------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------ - -------- -----=---------------------------------------- ------------------ ------------=----------- ------------- <br /> -------------------------------------- <br /> ----- - ---------------- --- --- --- <br /> ------------------------------------------ ---------------- - ------ <br /> Final InsP --------------------------------Date --------T---------- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />