69-1058 - Laserfiche WebLink

Home Browse Search

FOR-OFFICE.USE: ,APPLICATION FOR SANITATION PERMIT o ` - ------------------------------------------- Permit Nooff.-l�r i (Complete in Triplicate) ----- __._-_________--__-___________________________________ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: /CD/O.� / /� O. JOB ADDRESSAOCATIOA/- ci�--------� a 6.1_-=------ l Ae'1-------------_._-- S 1. ----- - - --- _CENSUS TRACT ----------------1_------- Owner's Name ----TQC:-------- ------------------------------------- ------------Phone -- �aa -- -g�� Address -4ZQ ' C C -- Contractor's Name -------- -------------------------- License # ------------------------ Phone -------------•-------.--•__--- Installation will serve: Residence partment House❑ Commercial ❑Trailer Court 10 Motel ❑Other -------------------------------------------- Number ------------- ----------------------------Number of living units.._'---/ Number of bedrooms _ -_..Garbage Grinder ---Y_ Lot Size -- -v_ �` _______________ Water Supply: Public System and name ----------- -------------------------------------------------•------------------------•---------Private Character�of soil too depth of 3 feet: 'Sand Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ - Clay Loam EJ - ' Hardpan Adobe Fill Material Ah).... If yes, type ---------------------------- . ' p ❑ E](Plot .plan, showing size of lot, location .of system in relation to wells, buildings, etc, must be placed on reverse• side.1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) w PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size______ _________________________________________ Liquid Depth ___--__-_-_________,___-- T� Capacity ----------------- Type ------------------- aterial------- ----- ------- No. Compartments ---------- Distance to nearest. Well ------------------------- ----------Foundation`_--------------------- Prop. Line ---------- .-..._ LEACHING LINE �o. of Lines _-___ ______________ Length o ea h line_-_-_� _--___----_--- Total Length _-_- --- .l. ._.:__ Type (---_Depth Filter Material _____1 q' Box �-------- 7 e Filter Materia! _-�_ -- ----------------------•- :_-- Distance to nearest: Well ________________________ F undation ------------------------ Property Line `' SEEPAGE PIT [ ] Depth ____________ _______ Diameter ---------------- umber --------- ----------------- Rock Filled Yes ❑ No'(I Water Table Depth ______________ ------------Rock Size --__________.____-_ Distance to nearest: Well ------------------------ __ __________Foundation --------------------- Prop. Line ........._...t..... REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------- --------- Date ---------------------------------- Septic Tank (Specify Requirements) ----------------------------:----------------- ---------- 5 Disposal Feld [Specify Requirements) .-- � - ----------lG�__--- -- -----------`-_! ---_---- -- -----------p--- n �1 r� �' =---------C� ` ��,r-��f E 1f� --------Fn-__k4-------ki�-E�------------------ --------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Nome owner or licen- sed agents signature certifies the following: _ "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signe ---` ----------------- -------------------------- ZONLY 4�A ff G /� " �!_"�_ "U -_ - -- _ ----- ------------------------ (1"�- (if other than owner) FOR DEPARTMENT U `� APPLICATION ACCEPTED BY `� ` DATI -- = �- - -- BUILDING PERMIT ISSUED - -- ------------------------------------------ ---------------------------------- ---DATE ------------------ ------------- ADDITIONAL COMMENTS ---------y ------------------ - - -------- - --- --- ----------------------------- L 7 rFinal Inspection by: Date`- ------ ---- SAN-JOAQUIN LOCAL HEALTH DISTRICT v 1 E. H. 9 1-'68 Rev. 5M