Laserfiche WebLink
FOR OFFICE USF <br /> APPLICATION FOR SANITATION PERMIT <br /> d 7 <br /> .......... <br /> Permit No. -.7....-.. <br /> (Complete in Triplicate) <br /> .. . .... ..... <br /> ...... <br /> ...........I <br /> •„................... This Permit Expires 1 Year From Date Issued Dote Issued .................... <br /> Application is hereby made to the Son Joaquin loco! Health District jar a permit to construct and install the work herein <br /> described. Ttiis appli;otiun is made in compliun,.e with County Ordnance No. 549 oncf�exis�g Rules and Regulations: <br /> .. ,,`�/.-• <' . . ... ... .` ......... .. ./......:..:.!.� ..:•.CENSUS TR <br /> ACT <br /> JOB ADDRESSACC�TION „..' _ . ' .....Phone ....................................jJ, ................................... .....Owners Name <br /> ,.f. �'L �.` ..:l. A;,.. ........... ............ ... ...............City '.......-.. .......-................ <br /> Address <br /> `� r�_ c. ,.. License Phone .............. <br /> Consroctor s Name .......a:......:.:.................................................. <br /> Installation will serve: Residence Apartment House 0 Commercial ❑hailer Court 0 <br /> Motel ❑Other............................................ <br /> ` :...Garb❑ a Grinder .--......... Lot Size ........... <br /> Number of living units:.. . Number of bedrooms 9 ”" <br /> Water Supply: Public System and name .......................... Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ peat[I Sandy Loam Clay Loam F1 <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............................ <br /> (Plot plan, showing siie of lot, location of systen in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tr.,ik or seepage pit permitted if public sews is available within 200 fee!,) <br /> T [ ) S:PTIC TANK t j Size................................................ Liquid Depth .......................... <br /> PACKAGE TREATMENT Y ..... .......... <br /> CaPCapacity .... Typo ............. p <br /> ....... Material...................... No. Compartments ...................... <br /> Distance to nearest: Well Foundation ...................... Prop. Line...................... Z <br /> LEACHING LINE [ ) <br /> No. of Lines ........................ Length of each line............................ Total Length ............................ <br /> 'D' Box ....-... . Type Filter Material Depth Filter Material ............................................ <br /> . . <br /> Distance to nearest: Well .. ... ................ Foundation ... . .................. Property Line ........................ <br /> . <br /> SEEPAGE PIT ( ) Depth Diameter .-.- Number ............................ Rock Filled Yes ❑ No <br /> -...-...... . <br /> WaterTable Depth ................................................Rock Size ................................ 9 <br /> Distance to nearest: Well ............................... <br /> .......Foundation .................... Prop. Line ...................— S <br /> PEPA!R/ADDITION(Prey. Sani!ation Permit# ............................................ Date ..................................) <br /> . .........._ <br /> Septic Tank iSperify Regw—!--,ents', ......... .. ............... ............................. J......�. ..,....._....--..•....... <br /> Disposal Field (Specify Fequirement<) .... .......: .....: <br /> '-'...............:..1G'.-.. ........ ..-..-.......... .............................................r ...-...............-.-............... <br /> r -i� �•:.. . .................._........-.................... <br /> ............................................ <br /> ...:.. .... ............ .......... <br /> ..: <br /> (Draw existing and required addition on reverse side) <br /> 1 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 Roles attid Regulations .if 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 <br /> permit i srued, I shall not employ any person in su& manner <br /> as to become subject to Workman's Compensation laws <br /> Owner <br /> Signed .... .. . ......._. ....- ..._ .._ ....� .�............ _..................... . <br /> t,.., ;- title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... ::..:r.:.:..... .... ..........DATE ........................ .................. <br /> ................ .......................... <br /> BUILDING PERMIT I ENTS ....................... .............................................. <br /> ADDITIONALCOMMENTS ...............................................................---_.-........... ...........-..•..---....... ... <br /> ................................... <br /> ......... ....................."-............................... ..................................... .... ......-......... .......................... .:..-............,..:r:.............. <br /> G� <br /> .......... ......................................:.......... .......... Date :,;<. .....�:_.-............ . <br /> incl Inspection by: ......,:.... ..:....:.. <br /> .................................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7/723 4 r <br /> E. H. 13 74 1-•68 Rev. 5M <br /> I <br />