Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ------------ ------------------------ ------------ <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> -------------------------------------- <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 ith County Ordinance�N0. 5.49 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCA N ---l-----�-------- --------- --- ------------------- --- ---- "-------- f---------------- <br /> .CENSUS TRACT ------------------------ <br /> --- -----------------•---- ------------Phone ---------------- - <br /> Owner's Name -_- - -- _-L ---------------- <br /> Address --- -------,. D - ------------------- --7- c `� ---. City ------------------------------------ <br /> Contractor's Name -----�� ---`I1---sL_t--- ------------------c-------------------.License # -/If M2�hone --------------------------_.._ � <br /> Installation will serve: Residence JX Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑ Other -------------------------------------------- l : <br /> Number of living units:-------I._.. Number of bedrooms -_-___Garbage Grinder ___________ Lot Size -----�y_.G -R_______________ <br /> Water Supply: Public System and name ______________________________ Private [� # <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑' Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <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,) Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] 1,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 /> V 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 /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------_---------____. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _______________________-___-______} + <br /> r <br /> Septic Tank (Specify Requirements) ry.�� ----- ------ <br /> Gz="1�1�C.�Lr�L - -- - ------ --- ----- - - --- -- ----------- -------�•----'--------�--- <br /> Disposal Field (Specify Re uirements) __ __ __ I_?ea_cx___ �._ -_ <br /> --------- dr•� ! ------ -- ----------- ------- ------------------------- --- — ------------------------------------------------- <br /> ---------------------------------------------------- ----------------------------------------------- ------------- <br /> ---------------------------------- <br /> (Draw existing and required addition on reverse side) r <br /> I hereby certify that 1 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 /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becom blect to Workman's Compensation laws of California." <br /> Signed --- ---- --------------- --------. Owner <br /> ------------- <br /> By --------- ---- --------- -- <br /> = Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------- ------------ DATE �- �� P, ---------------- <br /> BUILDING PERMIT ISSUED - - -- ---------------------------- ------------- ------ DATE --------------------------- <br /> ----------------�---------------- -------- --------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------- ------ ----------- --------------- <br /> ---------------------- ------------------------------------------------------------------------------------------ -- - <br /> --- -- --------------------------------------------------------------------- -------z------------- <br /> - ---- <br /> Final Inspecfiion by: Dater J� / -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />