72-96 - Laserfiche WebLink

Home Browse Search

FOR OFFICE usE: APPLICATION FOR SANITATION PERMIT --- ------------- (Complete in Triplicate) Permit No. ---------=---------------------------------------------- This Per Expires 11 Year From Date Issued Date Issued------------------------------------------ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _---6� - ---1`' -r'"0f_ --- i1 _�f. --------------CENSUS TRACT -------------------------- Owner's Name _. y_r_0Vf-Z ------- --------------------------------------.�... -----.-Phone ------------------ Address ) --- -------------- Contractor's ------------ •-.• City v/ l' va. /r f_. f�/ fay Contractor shame --- - ��.---- - •---- �� --f----`-"�------------------------------License �`�-�---.-------------- Phone - - --------- el Installationwill serve: Residence ❑Apartment House [K Commercial []Trailer Court ;❑ Motel ❑ Other ------------- --------------------------•--- Number of living units: Number of bedrooms -----------_Garba a Grinder ----_____._ Lot Size __________________________________________ Water Supply: Public System and name �iA� 7/1r2Op2----4_(!_[1_�>�'�-f r'�._10' -4------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'[W Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size/Number -- --------------------------------- Liquid Depth --_----------------------. Capacity ---- ----- --------- Type ----------- ------ ial---------------------- No. Compartments -------- ............. �l Distance to nearest: Well ---------- ------ _______Foundation ---------------------- Prop. Line ___ .................. LEACHING LINE [ ] No. of Lines Len th ofline______________________ Total length ______.____. 'D' Box _.__--- ---- Type Filter Mat rial ___ ______Depth Filter Material -------------------------------- ........... Distance to nearest: Well ________ ____________ dation ____ ------------------- Property Line SEEPAGE PIT [ ] Depth -------------------- Diameter ____________ mber __._.____-__-__---------____ Rock Filled Yes ❑ Noi❑Water Table Depth ------------- ----------------- -------Rock Size -------------------------- ---- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ________ _______ --------------- Date ----------------------------------) `9 Septic Tank (Specify Requirements) --- ----- ------------------ -------------------------------------------- ---------------- --•----------------------------- Disposal Field (Specify Requirements) -------- ------J ------ ------------------- ----------- - ---------- ------ - ---------------------- ---------------- ------------------- -------------------------------------------------.--------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman,s Compensation laws of California." Signed ----- - --; - --------------------- Owner ---- ----- - ------------------ By ------ Title ---- -------------------------- ---------- ---------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- - ------------- -- -------------------------------------------------------- DATE ---- ." �- -� ------------ -- ------- BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE -------- -------------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------- --------------------------- ------------------------------------------ ------------- ------------------------------------------------------------------------------------------------------------------------ ---------- ------------------------------------------------------------- -------- - - Final Inspection by -- -----------Date __� �3r-F-�----------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M