Laserfiche WebLink
APPLICATION FOR SANITATION PERMIT <br /> .2g----------- (Complefeln Triplicate) Permit No. <br /> ---------- ............................................ <br /> -----------------------I.......I......................... <br /> This Permit Expires I Year From Dale issued Date issued <br /> Application is hereby made to the Son Joaquin 1.6cal Health District for a permit to County constructand Install the work herein <br /> Ordinance No. 549 and existing Rules and Regulations: <br /> described. this application is made in compliance with C 0 k <br /> JOB ADDRESS/LOCATION <br /> ......i4mAk ..Lu? .1 Q <br /> Nwlo.-CENSUS -CRA <br /> i ............. <br /> Owner's Name <br /> ............... ....... <br /> ...Phone .... <br /> Address <br /> ---------------- <br /> C - - ----------------- <br /> .14... city . .......... ..................k. <br /> Contractor's Name ... .....( <br /> /....... ............. ........................License ..... Phone <br /> Installation will serve: Residence []Apartment House 0 Commercial oTraller Court 0 <br /> i Motel0 Other....E044.I----------- <br /> Numberof living units:_.-.. Number of bedrooms ...a_—Garbage Grinder Lot Size .10_11cec's........... <br /> Water Supply.. Public System and name <br /> ame .... ......................... <br /> ................­........ Private's <br /> ...................... ............................ <br /> Character of soil to a-depth of 3 feet. Sand Ig sift 0 Clay 0 Peat 0 Sandy Loam C1 Clay LOOM 0 <br /> Hardpan 0 Adobe 0 Fill M6terial ............ 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 /> I <br /> PACKAGE TREATMENT ' .[ ] SEPTIC TANK f Size....... ...... <br /> 1. , :.............. ...... Liquid Dept' ..r.................. 9J <br /> Capacity — <br /> Type _------------ .... Material----_---_---------- No. Compartments ........................ 5� <br /> Well ...... 4-; <br /> Distance to nearest: .............. ............. .Foundation ------ ................ Prop. Line _._:_....I............ <br /> LEACHING LINE No. of Lines ......................... Length of each line----......-...-_.._.. ...... .Total Length ............................ <br /> Box --- Type.Fifter Material .....................Depth Filter Material ...... .......................... <br /> Distance to nearest. Well ......................... Foundation __.................. Property Line ........................ <7 <br /> SEEPAGE PIT Depth - <br /> ......I--- ----- ................ mber ....... ....... Rock Filled Yes r❑ <br /> . <br /> 0 Diameter Nu <br /> 1 _1 No (3 <br /> Water Tab6 Depth --------•___----_. .-.-Rock Size ..... p <br /> Distance to(,nearest: Well .................. ------_---- ......Foundation .................... Pro . Line ..................... <br /> '!EPAIt/ <br /> M. DITION(Prev. Sanitation gPermlt# --:•--:..._....-----........................ Date .............................. <br /> Septic Tank (Specify Requirements) -------- <br /> ­ <br /> ........... <br /> Disposal Field (Specify Requirements) --­----­--- ---------................. ................ <br /> --------------------------------------•--.........---- •----._..... <br /> -------- <br /> ........................ <br /> -------------------------------------------- <br /> flDraw 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 Regulation's of the Son Joaquin Local Health:Dishict. Home <br /> sed agents signature certifies the following- owner or licen <br /> "I certify that In the performance of the work ior'which this permit Is Issued, I shall not employ any person In such man.nm <br /> as to become subject to Workmen's Compensation laws of California.- <br /> Signed ---- -- ----- Owner <br /> 411fz-�_ --7---------------­­ <br /> -------- --- -- -------------- <br /> By ......... <br /> ------ - ---------------- . ......... ........ ........ .................. <br /> fif other than ownerl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By .�........ ­---------------­.. DATE ---- <br /> ... . . ......... .................. <br /> BUILDING PERMIT ISSUED -------------- 4pi <br /> ADDITIONAL COMMENTS ----------------I .... ......­*----------- ----------------•- -------..._n-DATE _---- -- .. .... <br /> -------------------- -------1"1_11------------------------F-1...... .......I....................... --------------------------------- .......................... •------._...-.....-.......... -. <br /> -------------------- ------------- ------ <br /> - ---------11------------- ------------ ----- ------- ---------------- ----------------------------- . --- -------------------I—---------­........ ....... <br /> ­­­.......................... .... ....� ­.................................... <br /> ------------- --------- <br /> -------- ------ ------------- -7------------/--------------------------------------------------- --------------- <br /> Final Inspection by. ............. -- ---- <br /> A- <br /> EH 13 .2L 1-68 Rev. 5M K_- --- ---- --------------------------- ------------------------- ...Do <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />