Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' <br /> n � ,r--i__ �7_ rr�, <br /> Permit No.-----� )Complete in Triplicate) i'o '= `�� =��ta I Date Issued-- . This Permit Ex ires 1 Year From Date Issued- ---- - p--- - -- ------ <br /> Application is hereby:n`ade to the.San Joaquin Local Health District for a permit to construct and install the work herein <br /> with County Ordinance No. 549 and existing Rules and Regulations: <br /> described. This application is made in compli ce <br /> A14 ---------CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOC TION .___3----- ------------ ------2t°'--------- --- <br /> Owner's Name ._ ------ -------------- <br /> Phone <br /> S la+ - 1 � --- ---- City 3T- <br /> --------------- <br /> Address --- _i_ - -- ° <br /> --` License # -------- --- Phone ------------------------------ I <br /> Contractor's NaTITV - <br /> Installation wi`l'l serve: Residence DrA­partment House ❑ Commercial -❑Trailer Court i❑ <br /> Motel ❑Other ----------------------------- ------- ----- <br /> Number of living units:----- Number of bedrooms -_____Garbage Grinder:___-_4 Lot Size <br /> _ ? - Private [� <br /> Water Supply. Public System and'`ilame --------" _ <br /> } Character of soil to a depth of 3 feet:. ,. Sand'❑ Silt❑ ClaY ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material -_____._ -- If yes,type ------------------ " <br /> tion of system in relation to wells, buildings, etc. must .be placed on reverse side.] ( � <br /> {PI'o# plan, showing size of lot, Iota y -. � W <br /> p seepage pit permitted if public sewer is available Within 200 feet,] <br /> NEW INSTALLATION:: (No septic tank or <br /> ., <br /> PACKAGE TREATMENT SEPTIC TANK [ Size---------------------------------------- --- Liquid Depthth -------------------------- <br /> ------ <br /> -------- -----------.-: <br /> ---- <br /> ]. ------ Material----j- <br /> ----------------- No. Compartments <br /> ------ ---------- <br /> Capacity ----------------'--- Type ------------- PrLine <br /> to nearest: Well ------ --- -----------------------Foundation ---- <br /> Distance <br /> t _ Length of 'each line------------------ ------ Total Lengt F ----------- <br /> LEACHING°LINE [ } No. of Lines ------ --------- g <br /> I 'D' Box Type_Filter Material ______ ____________Depth Filter Material <br /> Distance to nearest: Well ------------------------ `Foundation ------------------------ Property Line ____." <br /> Well <br /> SEEPAGE PIT ['] Depth Dia'meter� <br /> Number Rock Filled Yes '❑ No �❑ <br /> -- ---- <br /> Waterr7xa <br /> ,ble Depth Rock Size -�-".-------------------------- <br /> Foundation -------- ---- Prop.•- <br /> Distance,to nearest: Well ----------------------------------------- <br /> .:1 <br /> ----------- ------------------------ - <br /> . ---- ---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------- Date ------------- ----- - <br /> ' <br /> Septic Tank {Specify Requirements) ___--___ �'�'� <br /> Disposal Field (Specify Requirements)-"----------------.--------------------------------------------------------------------------------------------- <br /> ' - ---------- ---- ------------------------------------------,--------------_---------------- <br /> ---------------------------------------------------------------------------------- <br /> ---------------- <br /> b ' <br /> ---- <br /> ------------------'- <br /> (Draw existing and required addition on reverse side) <br /> t I hereby certify that,l 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 Sari Joaquin Local Health District. Home owner or licen- <br /> I 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." <br /> t Signed By __- -."- ' Owner <br /> -------------------------- Title ._. ----------------------- -----------------"---- --------- ---------- <br /> (If other than owper) <br /> FOR DEPARTMENT "LISE ONLY <br /> APPLICATION ACCEPTED BY -------- ------------------------------ --------- DATE <br /> DATE -- --------- ------------------ ---------- <br /> BUILDING PERMIT ISSUED ---------- -----------------�;=" <br /> ADDITIONALCOMMENTS -------------- =------------------------------------------------------------------------ ------- <br /> ----------------------------------------------------------------------------------- -------- <br /> __________________________________________________________________________________________________________________________________ �-------- _ <br /> ____.________________________________.___________ _________.____.____ ____._________._. -------- <br /> ----- 2--- --- --- <br /> ---------- <br /> Date i <br /> v . Final inspection by: .__._�--e-� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P <br /> �i E. H. 9 1-'68 Rev. 5M ', <br />