Laserfiche WebLink
FOR OFFICE USE: } <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> ----------------=---------------------------------- <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> _ <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 with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION . 1 ------ '- ja"`c - ------------------------------- CENSUS TRACT -------------- -- ----- <br /> Owner's Name i -E?i�--------1` ,9 d -C?.iYZ.Y.t----------------- •---------------------------------- -----------Phone` X� <br /> Address L- a� * Ci#y ?fit c/ <� a <br /> Contractor's Namet - l [Z�4 License # f-- Q Phone <br /> Installation will serve: Residence [)g Apartment House❑ Commercial:❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units------------- Number of bedrooms ___.--------Garbage Grinder ------------ Lot Size --------------- <br /> Water Supply: Public System and name -.---,----------------------------------------------------------------------------------------------------------Private E i <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 7l <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plotflan,: 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 f ] ze------------------------------------------ ---- Liquid Depth ---------------------.----- <br /> Capacity ---- --------------- Type ------ ----------- Material---------------------- No. Compartments ------------------•--- <br /> Foundation ---------------------- Pro Line ---=------------- <br /> LEACHING <br /> -•--- --- <br /> Distance to nearest: Well ____ _____________________________ P• <br /> LEACHING LINE [ ] No. 'of Lines ----------------------- Length of each line-----_---------------------- Total Length ­------------- <br /> ~Box ------------ Type Filt Material --------------------Depth Filter Material ----------------------------------.......... <br /> Distance to nearest: W ------------------- Foundation ------------------------ Property Line ----_-___------.-..----- <br /> SEEPAGE PIT [ ] Depth -------------------- iameter ----____-__-_--- Number __-..-------__---_--___---- Rock Filled Yes ❑ No <br /> Water Table Depth ---------------------------------------•--------Rock Size ------I <br /> Distance to neare : Well ----------------------------------- --Foundation -------------------- Prop. Line -----_--.-----------.. <br /> REPAIR/ADDITION(Prey. Sanitation Per t�# -------------------------------------------- Date ---------------------.------------} <br /> Septic Tank (Specify Requirements) ---------------------------------�--.-J------4----------------- ---------------------------------------------- ---------------------------- <br /> Disposal 7Z"Vf <br /> --------c��-- -- - ----- -�- <br /> (Specify Requirements) ----4ZV(---------1446 tyf � <br /> - ?---------A'� �-------&� ------ --------------------- <br /> a. ---------- ---- <br /> ------------------------- <br /> ---------------------------------------- <br /> --------=-------------- --------- <br /> ----jam-�f-�- � --'�`-`�'f - <br /> I <br /> __ -------------- ------ <br /> (Draw existing and required addition on reverse side) <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 /> Signedr Owner <br /> BY ------- Title <br /> ------ --- <br /> (If other than own- <br />{ FOR DEPARTMENT USE ONLY <br /> f <br /> APPLICATION ACCEPTED BY ------------- -` - ---------------- ------------------------------------• DATE ...... ='� �� -------------------- <br /> BUILDING PERMIT ISSUED ------- ------------- ----------------------------- -------DATE ------------ ------------- ------ --------- <br /> ADDITIONALCOMMENTS ---------- -------- ------------------------------------------------------------------ --------------------------- <br /> ---------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------- <br /> --------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I ----- --------------------------------------------- �} -------------- -------------------------------- --- --------------------------------------------------------- <br /> FinalInspection bY- ------------------------- ------ ---------------- -----------------------------.Date __ -.,. ---.----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />