Laserfiche WebLink
t-UK ut-H t uat: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------•----- Permit No. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued <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 /> JOB ADDRESS/LOCATION ) l <br /> �/- /U - CENSUS TR - -\17 <br /> AC <br /> Owner's Name -- Ph �e =' <br /> �. <br /> Address �� //_ ----- - Y <br /> f , <br /> Cit - �.................................. <br /> Contractor's Name -----_-- j lrc. _-_ ------ _ _ ..-� skl ,_.License �L�Q..-3 _ _ Phone ______________________________ <br /> Installation will serve: Residence ❑ partment House❑ Commercial OTrailer Court ❑ <br /> 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 a depth of 3 feet: Sand'❑ Silt❑ Cjay ❑ Peat❑ Sandy Loam •❑ Clay Loam <br /> Hardpan ❑ Adobe Z 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 ____-_-_________-_________ <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line __________-___________ , <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length ----------- ................ <br /> 'D' Box ------------ Type Filter Material __________________•_Depth Filter Material -------------------- ....................... <br /> Distance to nearest: Well ________________________ Foundation ----- ------------------ Property Line ___________-______-_____ <br /> SEEPAGE PIT [ ) Depth ----- Diameter _________________Number - -------------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size ------------------------__------ <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------- -------------- ------------------------•----•-------•----•-- -------------------------------------------------------•----- <br /> Dis o I Field (Specify Require nts) -------- R ---/� • --•-------------------- ,- <br /> jf­ <br /> !� 1 t-----�-`- -------- ---- -('-f/'�_ --'-- `•---_- ----------------- <br /> X - S'�-- ---- -- -- - ------------------------------------------q <br /> (Dr existingand 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 becom subject to Workman's Com ensation laws of California." <br /> Signed ----- ----- ------------- - ---- Owner <br /> - ------ ---- -- -- - - ------------- <br /> BY Title ---------- <br /> - t----- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-to=-Aj�---- --- - - DATE ^3-0-10 <br /> BUILDING PERMIT ISSUED -------- -------- ---- ----------------- <br /> --------------- ------------------------- --------------DATE ---------••------•------------------------- <br /> ADDITIONAL COMMENTS -, t_?S 6 - ���'�?e---------------- ------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------- --- - -- --------------------------------------------------------------------------------------------------------- - - <br /> ------ - --- <br /> Final Inspection by: -___ - <br /> - --- -------- ------------- --- ---- ---- - --- - ------- -------------------------Date -7-3 <br /> AN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />