Laserfiche WebLink
FOR OFFICE USE: APPLICATION 4FOR SANITATION PERMIT <br /> - --- --------------•--------- - ---7D--/O� <br /> (Complete in Triplicate) Permit Na- <br /> -------- -- -------------------------------------------- <br /> --__-_________________________________________________ This Permit Expires 1 Year From Date Issued <br /> 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 Orb' ce No. 549 and existing Rules and Regulations: <br /> zz A <br /> JOB ADDRESS/LOCATION ._ _, 571 --------- ---------------------- CENSUS TRACT -- <br /> ct,�f c <br /> Owner's Name ------- ------ -- --- -- Phone <br /> Address - ~7WQ 'CitY <br /> {- ---------- ---------- f <br /> Contractor's Name --------------- ----•---- --J_ -cam ---------.License # t ;-5--��--- Phone . 2_ -6_:`_------------- <br /> 7 <br /> Initallation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other --------`-'=------ --------------------- <br /> Number of living units:----- ---- Number of bedrooms __�-___Garbage Grinder ------------ Lot Size ---- L/ <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 /> A Hardpan ❑ Adobe lb� 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: 1No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size_____________________________.____.____--------- <br /> -- `Liquid Depth ______________'Ii______. <br /> .t - <br /> ` Capacity -------------------- Type -------------------- Material---,-------------- --- No. Compartments -------------- <br /> Distance <br /> -----•------Distance.to riearest: Well ________ ____________Foundation ______________________ Prop. Line ______-__--_-_-_-___ <br /> LEACHING LINE [ ] No. of Lines _______ ______________ Length of each line--------------.------------- Total Length ---------_------------------- <br /> 'D' <br /> -___-- :.--_•__'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- ----------------------- <br /> Distance <br /> _----_--- ------Distance to nearest: Well ------------------------ Foundation ------------------- Property Line ---------.______-_-_-___ <br /> SEEPAGE PIT { ] Depth --------------- --- Diameter ---------------- Number ---------------------------- hock filled Yes Q No i0 <br /> Water Tah1e Depth ------------------------------------r --------Rock Size ------------------------------- <br /> Distance to.-nearest: Well ---------------------------�'-----------Foundation -------------------- Prop. Line ---------------------- <br /> f7AIR/ADDIT#ON{f rev. Sanitation Permit# --------.-!--------------------------------- Date ----------------------------------1 <br /> Septic Tank (Specify Requirements) --------------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) -- - ---------- -- <br /> ---------------- ---- -- --------------------- ----- --_ <br /> -- <br /> --------------------------------------------------------------- ---- - <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 /> Signed ------ Owner <br /> BY ------- -/------`- - ----`-- - ----------------------- Title ------ <br /> F�a^ <br /> (If of a than owner) ,. <br /> FOR DEPARTMENT ONLY <br /> APPLICATION ACCEPTED BY - - ---------- DATE ---- _ __7d <br /> BUILDINGPERMIT ISSUED --------------- --- ------------ -----------------------------------..------ ------------------DATE ---- --- ---- ----------------------------- <br /> ADDITIONALCOMMENTS ------------------ ---------------------------------------------------------------------------------------------------------------=--------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- ----------------------- ---------------------- ---------- ------------------------- --------------------------------------------------------------- <br /> -------------------------------�------- <br /> Final Inspection by: - :. --- ---------- -------Date 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 7L <br /> Final <br /> E. H. 9 1-'68 Rev. 5M <br />