Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No: _-��_=/6 <br /> _ _ ___-__________-_-_____ This Permit Expires ] Year From Date Issued <br /> Date Issued <br /> __________ _______________ -___ <br /> Application is hereby made to the San Joaquin Local Health District for ❑ 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 /> JOB ADDRESS/LOCATION .- -�Q�_Q__--, ��_`� ----t-�.---------�---��-------------------------CENSUS TRACT ----------------••-------- <br /> CC <br /> Owner's Name ---------------b -------- ------------ <br /> ---------- ------- -f- <br /> -------Phone ✓a_t'o?sP.----------- <br /> Address ---- ----------------------- r � _ � C City I <br /> Contractor's Name ------------ --- --- i 5�----- - --- _License # ------ Phone�6 <br /> Installation will serve: Residence�4 Apartment House❑ Commercial❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-----t_--- Number of bedrooms -----3----Garbage Grinder ------------ Lot Size ------ - ------------------- - <br /> Water Supply. Public System and name ____{__________________ _ ____________-Private f f <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: <br /> [No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size------------------------------------------- ---- Liquid Depth ---------------_-------- <br /> Capacity - ---------------- Type -------------------- Material--------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ___•__--------------- W <br /> LEACHING LINE [ ] No. of Lines -----------------i�l, ,f Length of each line---------------------------- Total Length -----------._.-._.--------_. <br /> 'D' Box ------------ Type Filter Material------------- =--Depth-'Filter Material ---------------------------.-___--__-----_-_ <br /> Distance to nearest:'Wall _______ _- _.______ Foundation --------------------------- Property Line ------------------------ <br /> SEEPAGE PIT Depth ---_--_------------- Diame er'-_'""_---. Number ------------I------- = _�RockRFi(led Yes EJ No C] <br /> t Water Table Depth = )_ -------- ' - x- Rock'Size -------------------------- <br /> i <br /> ----------- ------;' Distance to nearest: Weil'---_'----------------------__ ...........Foundation-------------------- Prop. Line -------------_•----••- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _________ ___________ __r=- ------- Date---__.:------_----------------- <br /> Septic <br /> _-.-- _ -Septic Tank (Specify Requiremerits) ---------------y` s-'_J_ /J /} <br /> ----- - --------------- <br /> Dis osa Meld S bcif Re uirements) __ , r <br /> P (► I Pf Y q v ------------------- - --------•--------------- <br /> --------------- =- -----= ---------------------- <br /> I v ,1 <br /> ' (Draw-Txisting and required addition on reverse'side) �. �, <br /> I hereby certify that I'have prepared this application and that_ tk 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 /> k <br /> Signed -- --------- = 3____ +_ --------- Owner <br /> -------------------------------- <br /> BY ------------ -----w------ - ` --------- -------------------------- Title .-------- ���t • ------- --------- <br /> (If oth t an owner) <br /> FOR DEPARTMENT ONLY <br /> APPLICATION ACCEPTO BY --- - --------------------- DATE -- ---- -Y---�-Z— <br /> BUILDING PERMIT ISSUED ------- -------- I ------------------- ------------ ------.---­------------------- DATE_-------__------------- ---------- <br /> ADDITIONAL COMMENTS --------------------- <br /> ------------ ------------------------------------- -------------------------------------------------------: --;--------1----.----------------------------------------------------------- <br /> --------------------- ---------- <br /> _________________________________________/ __-__ ______-___ _ _____-.____ __ _. - _ ._______-____-_-_--__.____.__-________--___.-_-______ - �f <br /> Final Inspection 6Y -- - --- -- - - -- --•----------- Date ------ = <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />