Laserfiche WebLink
- FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - ------------------- q <br /> (Complete in Triplicate) Permit No. <br /> ,1 <br /> �( Date Issued <br /> ____-__ _Ll---- --------------------- <br /> This Permit Expires 1 Year From Date Issued <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 /> JOB ___ (�_______________________ADDRESS/LOCATION ! <br /> + �°' j� - <br /> ---------------------------- ---------------CENSUS TRACT -----------------_------ <br /> Owner's Name _�I ah_{_�-- --- /`�,? -t':r,-s? �--------------- --------------------- - - -Phone c , - / a <br /> Address {��f `_ (.� ` -- -------------------- ---. City/ �-t 11� �� ���----------------------------------------- <br /> Contractor's Name ------C_,)_-r _ /� f h --------------------------------License # ----------------- ------ Phone ------Z_ --- ------­---- - <br /> Installation will serve: Residence ❑ Apartment House,❑t,Comniercial ❑Trailer Court <br /> Motel ❑Other __`fy1�`c"(c t_----. _�'_: . <br /> Number of living units:_______ Number of bedrooms Z--------Garbage Grinder ------------ Lot Size _/ 7 1_a?-a .'ca ---------------- <br /> s�- <br /> Water Supply: Public System and name ---------------------- --------------------------------------------.------------------------------------------Private <br /> rg <br /> Character of soil to a depth of 3 feet: Sand;R 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size--- ---__rr_''_'.__- Liquid Depth . --------------- <br /> --------- <br /> _- <br /> Capacity -f-? 7 ��- Type _-� u' `�>-lMaterial___� 3_ �l-Wo. Compartments _� _________________ <br /> Distance to nearest: Well ____ ?_C'_j------------------Foundation _j--__-.- Prop. Line .---_-___._.-._-- <br /> r <br /> LEACHING LINE [ ] No. of Lines --- ---f_____________ Length of each line_____ '<1---------------- Total Length -__li ---------------- <br /> 'D' Box ------------ Type Filter Material -] _4.t 4:.-_Depth Filter Material ---4�_-----_----:----__________________ <br /> Distance to nearest: Well ---_-6_-_Z)-_---__ Foundation __/_0-- --------- Property Line ��__-r............ . .- <br /> , � <br /> SEEPAGE PIT [ ) Depth __-_c�___ -------- Diameter _--............. Number -----.____/_--------------,- Rock Filled Yes 'Q No i❑ <br /> Water Table Depth -------------------------------- ---------- ----Rock Size <br /> Distance to nearest: Well ---------- < - ---------------Foundation ------- --------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------—--------------------- ---- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 Work n's Compensation laws of California." <br /> Signed -------------------------- ----- Owner <br /> -, <br /> Y -------- ----- ---- - =-_�{ - -------- -- Title --------------------- -------------------------------------------------- <br /> (If <br /> ------- - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = ----------- --------------------------------------- DATE %� <br /> BUILDING PERMIT ISSUED --- -- ---- ------------------- ----------DATE ---- ----------------------- <br /> ADDITIONAL COMMENTS _____„lir` --otia� .�s I - <br /> _ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- <br /> ----------------------------------------------- - ----- - --- - -------------------=- -- --- <br /> Final Inspection by: ------------ ��----- ---------------------------------------- ----------- - ----------------------------Date ------� -�=-Wiz------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />