Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....... 77 J— <br /> _.... ........................... ...... <br /> (Complete in Triplicate) Permit No. _71S__................. <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described.This application is made I•n�compliance <br /> )with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/L TION ........l.O..7r�.7 / v.. uc?.- /R CENSUS TRACT........................... <br /> . pp <br /> Owner's Name ... ........................................... H� �:. leo.. ._... <br /> Lr►s+•......-- ��'JY1.fe!C��....._._... Phone <br /> � Address _.......�. ..7�9. .. Q..... �/(-•• ------Cit I... -...t.............................................. <br /> Contractor's Name...�. C ... ./.t c4C1+......................License#.-1 .... Phone <br /> Installation will serve: Residence 42Mpartment House 0 Commercial❑Trailer Court ❑ <br /> t. Motel❑Other........................................ <br /> Number of living units:............ Number of bedrooms ........Garbage Grinder ..... ... Lot Size ............................................ <br /> Water Supply: Public System and name........................................................._......._..........................................Private <br /> Character of soil to,o depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom,e -Clay Loam❑ <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{ ) Size................................................ Liquid Depth ...........................00 <br /> Capacity.................... Type .................... Material..................... No. Comportments ..............._.....—I <br /> Distance to nearest: Well ....................................Foundation......................Prop.Line......................J <br /> LEACHING LINE [] No. of Lines ........................ Length of each line............................. Total Length ............................ <br /> .Z <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................. <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................r� <br /> SEEPAGE PIT [ j Depth .. ................. Diameter .Number ............ Rock Filled Yes ❑ No C3 <br /> Water Table Depth ................................... ..........Rock Size..........••.................... f <br /> Distance to nearest:Well ........................................Foundation .................... Prop. Line .......-------------OS <br /> REPAIR/ADDITION(Prey. Sanitation Permit#............................................ Date .................................. S <br /> Septic Tank (Specify Requirements) ... w.al.................................... :..............•--............................_.............---•--............ <br /> Disposal Field jSpecify Requir fi�ntsl ...--- . ...�Q ..�, N.Q........ .....s� <br /> .......... .LD........_.�aqa............................................................ -----........---•-•-•-------....-------------------•--........_............------....----- <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 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 suW <br /> ' an's Compensation laws of California." <br /> Signed......... . Owner <br /> By......... G .......... _ . Title <br /> s c. <br /> (Ifner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.... . . ................•..........•-••.....•---............................... DATE......... ....... f-�- -------- <br /> BUILDINGPERMIT ISSUED................................................................_...................................._..DATE......-...._......._....................... <br /> ADDITIONALCOMMENTS.................................................................•-•--..--.............................._.........................I........................... <br /> .........-.._ .... ..................................................................................................................................................................................--. <br /> ...........I..... . ...............................................................................•-------_.................................•••....._•--.-.......__......._.. ---------------- <br /> ................................................ .._ .. .......... <br /> J.r•......... <br /> �r ,s <br /> FinalInspection by:............... .J/.•.............._............._..........................................................Date..1..(.. .. ..........._.... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y E.H.13 24 1-'68 Rev.5M x/72 3 M <br />