Laserfiche WebLink
FOR OFFICE USE: <br /> �'`"�PPLICATION FOR SANITATION PE_ Ti <br /> (Complete in Triplicate) <br /> Permit No. <br /> ---------- —- ------------ ------------------- <br /> ----------------------------------------_---------------- This Permit Expires 1 Year From bate Issued <br /> Date Issued _2_-W-20 <br /> k r <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 /> Fttt <br /> JOB ADDRESS/LOCATION . � �'� -:--- --CENSUS TRACT -------------------------- <br /> Owner's Name t ---- ---------Phone --------------------------- <br /> -`,� -- <br /> Address �L[� f- fC ;------ ----- Y ---------- -------------•---------- <br /> Fi <br /> i Cit <br /> Contractor's Name ....... <br /> -- --.-- --------------------:_- License # Phone <br /> I Installation will serve. Residence E(Apartment House,❑ Commercial:❑Trailer Court F-1[ Motel E- Other _ ___ -_ __ ti- llye -a...a,_. <br /> Number of living units:____f_-_ Number of bedrooms ___�i----Garbage Grinder _____________ Lot Size _______-_-_-_-----______________-_________ <br /> I Water Supply: Public System and name ------------------------------ ----------------------------------------------- --- ---------Private <br /> Character of soll to a depth of 3 feet: Sand L] Silt❑ Gay ❑ Peat❑ Sandy Eoam [Clay Loam '[:] <br /> r Hardpan ❑ Adobe 0 Fill Material ------------ If yes,type __________________________ <br /> t <br /> (Pl'ot 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 'J Size- � r <br /> [ l '[ ���__,_�'.1�._--X--'�--------------=---- Liquid Depth .--lz'�--------------------- <br /> Capacity <br /> -------------- <br /> Ca aci l-2flv Type (&,;,,-__-__ Material___OfX-0 ______ No. Compartments ____ __ � <br /> P tY - - - -- --- Yp - - p �---.-•--°---- J <br /> FiDistance to nearest: Well ---------5'&--__-___________________Foundation ---_L_a------------- Prop. Line _______S,___________ l� <br /> LEACHING LINE [� No. of Lines _______ g g <br /> Lines ---------------- Length of each line-------��--------------- Total Length ---------------- <br /> 'D' <br /> - --_--_-- _-- <br /> 'D' Box --------- Type Filter Material ------ - ------Depth Filter Material ------jq'1_.........----------------- --- <br /> 1 ' Distance to nearest: Well __________ __r______ Foundation -------1-0-1-------- Property Line ____A__f______________ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ----___-_------- Number -_-__-__-____________-______ Rock Filled Yes ❑ No !❑ <br /> Water Table Depth ----- --------------------------------- --------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------___--------Foundation -------------------- Prop. Line ________---___-__----- <br /> REPAIR/ADDITION(Prey Sanitation Permit# -------------------------------------------- Date ----------------------------------1 . <br /> ( Septic Tank (Specify Requirements) ------------------- -------------------------------------------------------------- -----------= --------------,<---------------------------- <br /> Disposal <br /> -------- <br /> ----------------- <br /> Disposal Field (Specify Requirements) ------------ --------------------------------------------------------------------------------------------------------------•--------- <br /> r ----------------------------------------------------------------------------------------------------------------- <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 /> 1 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 /> Fj "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 sub'ect to Workman's Compensation laws of California." <br /> Signed ------- - Owner <br /> --'Y �✓ - Title ----- -- --- -------&------------- ------------------------- <br /> j (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --. 7' <br /> - --- --------------------------- -------------------- ---- -------. DATE --------------- <br /> BUILDING BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS --------- ------------------------------------------------------------------------------------------------------------ ---------- <br /> - - --- ---------- <br /> ---- <br /> ----- ----- - -- ------ <br /> - --------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------, <br /> ------------------------------ --------------------- ----- <br /> I <br /> DateFinal Inspection bY- ----- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H, 9 1-'68 Rev. 5M <br />