Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ..... .......... 5..7 a <br /> .................... <br /> Permit No. ...��. .�:..... <br /> (Complete in Triplicate) <br /> ..............,...._...._..._.-......... ------ . <br /> " <br /> This Permit Expires t Year From Date Issued Date Issued ...2".:....�:. .� <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 with County Ordinance No. 549 and existing Rules and Regulations3: <br /> JOB ADDRESS/LOC ON _. <br /> 7r//^ ..../-1..- ' --�"'�'`�---- <br /> .....................................CENSUS TRACT .........................- <br /> Owner's Name .. '.----------•..................... ................ ................Phone ..........._........... ..... <br /> n <br /> Address , _ .cam �./.... City . .. _. <br /> _.... <br /> Contractor's Name __ .s................License # 198ldfoZ�-'-. Phone ...............I.............. <br /> Installation will serve: Residence[Apartment House 0 Commercial ❑'frailer Court <br /> Motel ❑Other............................................ <br /> Number of living units:.... Number of bedrooms 35.....Garbage Grinder ............ Lot Size ............. <br /> Water Supply: Public System and name ----------------•----- ................................................................. .. .............._Private <br /> Character of soil to a depth of 3 feet: Sand El Silt[J Clay ❑ Peat❑ Sandy Loam. Clay Loom ❑ <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 I ] Size.......................... ..................... Liquid Depth ..........................v <br /> Capacity -------------------- Type .................... Material...................... No. Compartments ----.................:k <br /> Distance to nearest: Well ....................................Foundation ........_-_........... Prop. Line ......................� <br /> LEACHING LINE [ ] No. of Lines ------ Length of each line..................... ...... Total„Length ......................:....� <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ . <br /> Distance to nearest: Well ........................ Foundation -__-....... ............ Property Line .................... <br /> SEEPAGE PIT O Depth -------------------- Diameter .......... Number ..-----------------------... Rock Filled Yes ❑ No <br /> Water Table Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .--------- ......... Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......................----------•---------- Date --------------------------------A <br /> Septic Tank (Specify Requirements) --------------•--.. ------------------------- ---------........................................................................... <br /> � <br /> Disposal Field (Specify Requirements) --- tea..... <br /> .. <br /> --------- --- -------- -------- ------- ------------ .......................... -.................................................. <br /> ---..__................................. <br /> .. <br /> IDrow existing and required addition on reverse side) <br /> I hereby certify that 1 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 Iicew <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." W <br /> Signed ------------------------ - ----------------------------- ---------. Owner <br /> B Titie ./ �. <br /> Y ---- -•-- - ----- r <br /> (If other than owner) <br /> R DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- -- --- -- --- ----------------------------------------------- ....... DATE .,.47. ._._...: <br /> BUILDING PERMIT ISSUED -------------------- ----------------------- -------- ........... -...DATE .... --•--------- <br /> ADDITIONALCOMMENTS ----------------- ------------------------------- ...........---------------------------------------------------------...-----...-•---..------..._-------•---- <br /> ------------------------------------------------------------------------------- - ----------------------......_--.-----------......-------------- .........................--------.....-... <br /> ------------------------------------------------------ ._.._..... ............... <br /> Final Inspection b - Date _.-.. . <br />{i EH 13 2h 1-68 }lev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> l <br />