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t FQR OFFICE USE: _ <br /> ,_—„---------- -- ------ .. -iPPLiCATION FOR SANITATION PERMIT -- <br /> ----- --- - �-•------------------------------------------- - (Complete in Triplicate) Permit No. __________________ . <br /> -7� <br /> Date Issued <br /> ----------------_--------_--------------- This Permit Expires 1 Year From 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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------0w-----------=----- ------CENSUS TRACT -------------------------- <br /> Owner's Name4_1j _ �� '_r '�l _x0 ''��-------------- -Phone <br /> ,cam -, _ -,. ------ — - <br /> Address ------------------- City 1 <br /> Contractor% Name._�XXC _Y______��� --------tom-,� -------License # _7,reg�V_ Phone <br /> Installation will serYe: Residence-K Apartment Housef] Commercial : Trailer Court '[3 <br /> 9 Motel F1Other ____ r <br /> I 1 <br /> Number of living units:-,:-1------ Number of bedrooms ______Garbage Grinder .%✓l�__ Lot Size ��-�X---��p----------••••- <br /> t i ” <br /> i 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 -----I.----- If yes,type ---------------------------- <br /> (Plot plan, showing size-of-lot—location.of,.system_in-relation to-wells,-b.uiId•+ngs, etc. must be placed on reverse side.) �r <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> I PACKAGE TREATMENT { ] SEPTIC TANK Size____iX .-,V—/ --------------- Liquid Depth _41' __'�______-___-____. <br /> • Cap0city/,2a0,/;, f TypeI iMateria No./ Compartments _ �._f <br /> , 1 -- / <br /> Distance to nearesfi: Well __-;S__ ________________________Foundation __ Q-------------._ Prop. Line _�a��-- :----•--- <br /> LEACHING LINE [4 No. of Lines -----/---------------- Length of each line-----'--- --------- ------ Total Length <br /> li <br /> 'D' Box/Vd.---- Type Filter Materia Fd_C&----Depth Filter Material - _ _____-------_------------------ <br /> _____ <br /> r 01 <br /> 1-11 <br /> i Distance to nearest: Well ----. _ Foundation .-le---------------- Property Line 5-_______________•--_ <br /> i SEEPAGE PIT f Depth __ _�__________ Diamete <br /> d f, Number -------�.____.- __--___-- Rock. led Yes No 0 <br /> } __Rock Si <br /> Water Table Depth -- Q ----------------------- ,w7,�- --- - ------ <br /> Distance to nearest: Well _____/Q ______________________Foundati _ _______.___ Prop. Line �.______-___-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------------------- ------------------------------ -- <br /> ----------------- ---------------------------------------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 Rales 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 su ect to Workman's om sation laws of California." <br /> Signed - - - - - --------------------------------------. Owner <br /> rl <br /> -------------------- Title ------------ --- - ------------------------------- -------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYef,_ ------------------------------- - --------------------------------- DATE ------------------- <br /> BUILDINGPERMIT ISSUED ........... ... ------------------------------------------------------------------------------._DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------- --- -------------------------------------- <br /> ----------------------------------------------------------------------------------------------------- <br /> - <br /> --------------------------------------------------------------------------------------------------- <br /> --------- ---------- -----=----------------------------------------------------------------------------------------------- <br /> ----------------------------- -= ------ -- --------- - =------------------------------------------------------------------ -------•---------- ----------------- <br /> ' ,J -Final Inspection by: -------------•---------------------------------------Date --- ---------------------- <br /> ------------------------------- <br /> SAN <br /> ----- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H, 9 1-,68 Rev. 5M: , <br />