Laserfiche WebLink
<'FOR OFFICE USE: APPLICATION 'FOR SANITATION PERMIT <br /> Pe <br /> ---------- ------------------------•- (Complete in Triplicaterm it No. --�� <br /> -� <br /> ---------------------------- --------------- N <br /> �,.. Date Issued <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 '`�-------------------------------- -----------------------------CENSUS TRACT _-S`��-------------- <br /> Owner's Name ----- ` � �<.0 - Phone <br /> Address ern -- x °yr = ` �'' City _,-------- -- ----------------------------------- --------------- <br /> �� x <br /> Contractor's Name <br /> --------License #• 4... - Phone - -------r�f ---- <br /> n <br /> Installation will serve: Residence t Apartment House,] Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:--/---- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ---------------------- <br /> . <br /> Water Supply: Public System and name ---------------------- ------------------------•-----------------------..--------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam,) Clay Loam 'E] <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.) f <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK;[ ] Size------------------------------------------------ Liquid Depth ---------------------.----- 0 <br /> 0 <br /> Capacity - ------------------ Type -------------------- Material---------------------- No. Compartments ------ ------- <br /> Di stance <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 [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------- ---- Prop. Line -----------.---------_ <br /> REPAIR/ADDITION(Prev, Sanitation Permit# --------.----------------------------------- Date ------------------.---------------1 <br /> Septic Tank (Specify Requirements) --- ---------------------------------------- - ... <br /> Disposal Field (Specify Requirements) Q :-z�-�-1----,'"" �K -------------------------------- <br /> a -- x -- s' t �------------------------------------------------------.. <br /> �a.. __-.----�-_. ______ _______ __-_-- <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 t in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to com subject to Wor an's ' sation�la-wsr of California." <br /> Signed --- ...... ----------------- Owner <br /> title --------I---------- <br /> t(Ifer than owner) <br /> FOR DEPARTMENT USE .ONLY <br /> APPLICATION ACCEPTED BY tj ------------------/--------- - ---------------------- DATE 'f.3~ --------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------- -------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS - -------------------------------------------------------- ---------------------------------------------------------------------- -------------------- ------ <br /> ----------- ------------------------------------------------------------------------------------- ---------------------------------------------------------- <br /> -------------------------------------- --------- -- - >=----------------------------------- -- ------------------------------------------------------------------------------------------------- <br /> Final Inspection by: --------- ---------- Da#e -67------ - <br /> --- -- -- -- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1268 Rev. 5M <br />