Laserfiche WebLink
FOR OFFICE USE: <br /> ------------ <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ...TS' l <br /> :.....:.......................:............:....... _.. <br /> ...................... This Permit Expires 1 Year from Date Issued Date Issued ... --7 S ) <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 rdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION r� 1 ........... _. <br /> ........CENSUS TRACT .......................... <br /> Owner's Name - ••-•........................................... .....................Phone 17/ [�... a <br /> c¢- ... .�........ --nn . . ........�._ <br /> Address - <br /> ---------------------.. City .. ... .0 .c�..... �. ....... .............---- s <br /> p - <br /> Contrattor's Name •.... . .........................License #�'.9Y,2 L-.- Phone . . <br /> Installation will serve: Residence Ig Apo ent House] Commercial ❑Trailer Court '❑ <br /> Motel ❑Other.........-...................... <br /> Number of living units:---- ...... Number of bedrooms .--- .-.Garbo e Grinder ............ Lot Size ..'� .X. -�............... i <br /> ..�.:. . <br /> Water Supply: Public System and name ................. _....--...... <br /> ...-.---.---•...........................Private ❑ { <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe.Ca Fill Material ............ If yes,type ............... ............ i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse aide.) <br /> NEW INSTALLATION: (No septic tank or seepage pit ,permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK t ] Size................................................ Liquid Depth .......................... <br /> Capacity ----------- ------ Type --------- .......... Material---------------------- No. Compartments . <br /> Distance. to nearest: Well ------------------------------------Foundation ..................._.. Prop. Line ...............:..... O <br /> LEACHINGU �NE [ ] 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 /> SEEPAGE PIT Depth ------. -------- -- Diameter ................ Number ---------------------------. Rock Filled Yes ❑ No ❑• <br /> Water Table Depth ------ -----------------------------------------Rock Size ................................ C� > <br /> -Distance to nearest: Well ------------------•................-----Foundation .....................Prop. Line,....................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..........................,...... <br /> :) <br /> Septic Tank (Specify Requirements) -----• Z - ----•---_•-------------------•---_---------------_•-----•.......................-._.......... <br /> DisposalField (Specify Requirements) ................. --------------------------------------------•_----•-..................------..............._..-----•-------- • -� <br /> - 6 <br /> -------••--••---------------------••------••---....:....--•---------•---_----.------ --- ------------------------ <br /> ------------- -------------•- ------------------------------------------------•..............I -=----•-•--........._---------..-----...._:................._....... <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 Rules and Regulations of the San Joaquin Local Health;District. Hone owner or peen- <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 -------------------------------- ---------------------------•--------------------- -------------- Owner <br /> By ---------•---- -----. Title --------------------- <br /> ( fother <br /> than owner) <br /> _ OR DEPARTM NT USE ONLY _ <br /> APPLICATION ACCEPTED BY ---- DATE <br /> y._._~ <br /> BUILDING PERMIT ISSUED <br /> ---------------•----------------------------------------------------------- --- DATE ---...-----...._.. <br /> ADDITIONAL COMMENTS ---------------------------••---------------------- <br /> --------- ------ ............................................ ---------------- -------••---- <br /> --------- - ---- -------- •---- <br /> �* �-} <br /> Final Inspection by- --------- - J- . ... ----...----------------...................Date _. .`... <br /> EH 13 2h 1-68 itev. 5m <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. 8/7h 3M <br />