Laserfiche WebLink
R OFFICE USE: � <br /> j,: ArLICATION FOR SANITATION PERMIT <br /> ------ Permit No. ' � <br /> This Permit Expires 1 Year From Date Issued _ _ , �_ <br /> (Complete in Triplicate) • <br /> ---------=------------------------------- --------------- <br /> Date Issued <br /> _ <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 adcompliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ,,3 c'31 E. � ^r c C 4 f <br /> JOB ADDRESS/LOCATION ._._. t�/�f7---e ^'1_�__� h� .�-G--_-- �_S _r_4_N._..._CENSUS TRACT -_----------------------- <br /> Owner's Name ------Co----------- --------Phoneq/lo' <br /> Address -,AFO-;------0------ -------------------------------------------------- City - ------- <br /> Contractor's Name ---------7f/It!_lc__._ �-------.License # ,�7 �'� -- Phone �_ �G <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ,❑ <br /> x � <br /> Motel E] Other C/I'"-— � <br /> Ai ___- '11,Ssj ory <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder _.---------- Lot Size _. 0--' <br /> Water Supply: Public System and name ---------------------------------------------- ----------------.Private <br /> ------------------------------------------------ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam p�,' Clay Loam 'E] <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,) 4 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size_.'f '( q p � <br /> Capacity f_U0------- Typef9_i?4---r aterial_ �'�--- No. Compartments __�............... <br /> Distance to nearest: Well __& t-_ ______________________Foundation _1.6............. Prop. Line .......... <br /> LEACHING LINE [4— No. of Lines ------y--------------- Length of each line_____V ------------ Total Length ___J_?�f <br /> 'D' Box Type Filter Material 144PDepth Filter Material r. <br /> Distance to nearest: Well __S ?------------ Foundation __/ ---r__________ Property Line -------- <br /> SEEPAGE PIT [ ) Depth ____---------------- Diameter ________________ Number ---------------------------- Rock Filled Yes '❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------------ n <br /> Distance to nearest: Well ----------------------------------------Foundation ---------------.---- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------- ------------------------------------------------------------------------- --------------------------------------------------------- <br /> Disposal Field {Specify Requirements) _____________ --------------------- <br /> ----------------------------------------------------------------------------------- -------------- <br /> -------------------------------------------------------------------------------- --------------------------------------------- --------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- --------- - -------------------------------- -----------------------------------------------------.-------- <br /> (Draw existingand 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 su lett to Work an's Compensation laws of California." <br /> Signed ___--__- ------------------------------------------------------------- Owner <br /> BY --------------- ------------------------- ------------------------------------ ------------------------ Title ----------------------------------------------------------- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- 0%4 ---------------------------------------------------------- DATE ---------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------ --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------- --------------------------------------------------------------------------------------------------------------------=--------------------------- <br /> ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- <br /> ----------------------------- ------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------ ------------------------ ----------------- -- - --- <br /> Final Inspection by: ---- ---- ---------- ----------------- ---------------------- Date �V-Z y (P <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />