Laserfiche WebLink
FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT ' <br /> -------------------------------------------------------- ro <br /> (Complete in Triplicate) Permit No: <br /> Date Issued <br /> ------------------------------------------ <br /> _________ This Permit Expires 1 Year From 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 /> © <br /> JOB ADDRESS/LOCATION - <br /> CENSUS TRACT -- - - ---•----------- <br /> .----__--9_G_-_�-- 4--- ���i/�,��-t ----------------------------------- <br /> Owner's Name --------/1__ j------- is+ ---------------------------------------------------- -------Phone F Y--------------------------- <br /> Address -------- ----------- ' If <br /> -------el— ------------------- City ------------------------------------------- <br /> Contractor's Name 'rrz -------------------------------------------------------=----------License # --- ---------- Phone ------------ ..__..-- <br /> Installation will serve: Residences Apartment House❑ Commercial❑Trailer Court <br /> Motel ❑Other -------------------------------------------- ] <br /> Number of living units:___-/_____ Number of bedrooms ------- ----Garbage Grinder ------------ Lot Size ._ ``-______________________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private,,] 1 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam CM <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�r] Size----- t-___ --- <br /> ----------------------- Liquid Depth ___1�_____________________ <br /> Capacity 1 -_Q 6- - -- Type .�- '- _------_ Material----���"_-------- Na. Compartments �--------------- <br /> Distance to nearest: Well ----.5 --------------------------Foundation ----4Q-_---_--__ Prop. Line _S~___________-___. <br /> LEACHING LINE [ No. of Lines ---�---------------- Length of each line----/0-0-'_------------ Total Length -_ .l______________ <br /> D' Box Type Filter Material /7_-`------------Depth Filter Material ---h_!--------_---------------I....... <br /> Distance to nearest: Well --- ----------------Foundation ---/&'------------- Property Line _____ <br /> SEEPAGE PIT Depth Diameter 3-3------- Number _._-__. _______________ Rock Filled Yes;® No i❑ <br /> Water Table Depth -----r ------------------------------------Rock Size ---1- --------------------- __ <br /> Distance to nearest: Well -169-0_-___________________________Foundation f-e--_._________ Prop. Line S __..____-___---. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------- ----------------------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ----------- ---------------------------------------------- <br /> ----------- -------------------- ---------------------- -----------------------------------------------------------------------------------------------------------------------------------•-- ---------- <br /> ------------------------------------------------------ -----------------------------------------I-------------------------------------,-----------_--------.--_---- ---------------_------ _ <br /> (Draw existing and required addition on reverse side) I <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 subject to Workman's Compensation laws of California." <br /> Signed --- -------- . `cmc X� ------------------------ Owner <br /> By ---------------------------------------------------------------- - - ----------- Title -------------------- <br /> - - - -------------- - - -------------------------------------- - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY - <br /> ---------------------------- -------------- DATE - -------------- <br /> --- --------------------- <br /> BUILDING PERMIT ISSUED* --------------------------------------------DATE ------------- ------------------------ <br /> ADDITIONALCOMMENTS -- - ---------------------------------------------------------------------------- ----------------------------- ------------------------------------------ <br /> ------------------------------------------------ ------------ --- <br /> ------------------------------------ - ----------------- ----------------------------------------------- ------- <br /> _ <br /> Final Inspection by: . ,.L s ----------------------- -------.Date ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT :C.- <br /> E. H. 9 1-'68 Rev. 5M <br />