72-1004 - Laserfiche WebLink

Home Browse Search

t FOR-OFFICE USE: 4 : r APPLICATION FOR SANITATION PERMIT ' (Complete in Triplicate) Permit No: __~f _ u- - --------- ----,------------.---_---________________--------------- This Permit Expires 1 Year From Date Issued Date Issued!d_=��_"7.. Application is hereby made"to the Sn Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance''with C unty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ---_ ��0---- - � -- ----------------------CENSUS TRACT _ Owner's Name ---- --- --------------- ------------ -------------------Phone Pho - z7 0 ' Address n------------------------ ----------------- city ---- ------------------ ------ ator's Name ----------Contr - - JLicense # l� __ ---- Phone Installation will serve: esidence Apartment House,❑ Commercial:❑Trailer Court I Motel ❑ Other __________________________ Number of living units_____________ Number of bedrooms ___+a�Garbage Grinder ------------ Lot Size -----5�.__ Water Supply: Public System and name __________________________ _ -----------------------------Private ❑ Character of soil to a depth of 3 feet: Sand:Q Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .E1 Hardpan ❑ Adobe 1P 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-------- .__t�-- ---__I___34 Liquid Depth ----------- Capacity __Capacity _� Type - - -- - --- - '.No Compartments --------..�- _Found • 0 -----cstena -- --- Distance to nearest: Well _ [ J No, of Lines ______________________ _ Length of each fine -_ at�on¢__/�__t_- --___ prop, Line -.5____-.__:_______- -------- --- -------- LEACHING LINE I �'- .___---_`_..______ Total Length __-____ 'D' Box ---I-------- Type Filter Material _________________t bepth Filter Material -------------------------- Distance _-- __ _Distance to nearest: Well ------------------ -- Foundation ------------------------ Property Line -----------..--._.-----_ SEEPAGE PIT [ J Depth ----- -------------- Diameter -------------- Number -____-. ---------.---__--- - Rock Filled Yes ❑ No i (� Water Table Depth ------------------------------------------------Rock Size ---------------------------- Distance -------------- ” - 'Distance to nearest: Well ----------------------------------------Foundation ----..-------------- Prop. Line --------------- ....... REPAIR/ADDITION(Prev. Sanitation Permit# !---------------- Date -------'._--=--=-----,------_-•_-] Septic Tank (Specify Requirements) ___ _ �C ----_ Disposal Field (Specify Requirements) ----------__---------------------------------------------------------- --------------------------------------------------------- ------- `---;` ,' ----------------- -------------------------I---- -------------------------------------------- -- `} (brave existingand required---------- Y y prepared this application and thaddition on reverse side] I hereby certify that 1 have at 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 "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 � r (If oth an owner] T-- FOR DEPARTMENT USE-ONLY-�� ` APPLICATION ACCE ED BY .----- ___ - -- --------� =� ---------�;- ------------------------- -DATE _Ao h-�_ro----- ------------ } - -- - BUILDING PERMIT ISSUED -1------------- -------- ---------------------------- -------DATE -------------•----- - ADDITIONAL COMMENTS ------------- -------- ---------------------- - ------------------------------- 1 ------------------ - - - - -- ------Final Inspection by: +� ------ ------- ---- -- -------- -- --- Date ---- b-�_ 3_ _ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M �t '