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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------ (Complete in Triplicate) $-_ Permit No. ------ <br /> ------ <br /> ---------- ---------- - Date Issued <br /> This Permit Expires I )fear From Date Issued <br /> -----------1�------------------- <br /> Application is hereG" made to the San Joaquin Local Health District for a per mr it__to- / <br /> _constr!uct_and-An3talt the work herein <br /> y " . <br /> described. This application is incompliance wi County incince No. r-A9 and existing RuI4's and Regulations: <br /> V <br /> JOB ADDRESS/LOCATION <br /> z�2 <br /> - -------------............CENSUS TRACT -------------- ----------- <br /> .... .. <br /> ..... -- -- ------ ---- ---------------- ---------- --------Phone --------- <br /> Owner's Name ------------------- --- - --- ------------- <br /> Address'---------- ----------------------- ---- ---I--- -- -- -------------------------------- City ---------------------------------------------------------------------------- <br /> ------------ <br /> Contractor's Name ------------ -_-.License # ---------------------- - Phone 440�—Z442_7--- <br /> ---- <br /> Installation-w.ill-serve--- Re,;idence-E]-Apartment-House�-E]-Commercial-:[]Trailer-Court-,E]- <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----/,-..--.Number,of.bedrooms UGGH de ------ Lot Size ----__--------------------------_-------. <br /> Water ------------- <br /> Water Supply: Public System and name -----------------------------Private J <br /> ------------------ ...... <br /> [Pleat El Sandy Loam ED Clay .E] <br /> ,.Loam <br /> I <br /> Character of soil to a Aepth of 3 feet: Sand'[:] Silt E] ClayLL-0 41 <br /> , J� <br /> Hardpan E] Adobe' � Fill <br /> Ma t�e­r i a I ------------`If yes, type ------ --------------------- <br /> 'A <br /> (Plot plan, showing Le of lot, location of system in relation to wdlIs, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION:I lNo septic tank or seepage pit permitted if p1l3lic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTICITANK{ j Size------------- ---------------------------- ----- Liquid Depth ------.-----------.------_ <br /> Capacity <br /> Type Mat <br /> real---------------------- No. Compartments -------------------- <br /> ---- ----- -------------------- , <br /> Distanceto nearest.. Welljv_T�,�--------------------------- ---Fo6riclatibn ------I---------------- Prop. Line ----.--.-- _-__--- <br /> �` J�.J 1'�A <br /> LEACHING LINE -No-Of.)Lines Length of eciEfi line._--- ------------- --- Total Length ---------------------------- <br /> ox .... T_, "R�_M Jtdrl ci I <br /> 'D' ----- -------------Depth Filter Material -------------------------------------------- <br /> Au i <br /> i sta nce-to-nea rest:irWel I ------------- ......304ounclation -----------------I------ Property Line- ----------------------- <br /> - <br /> e <br /> SEEPAGE PIT AptH) __1----- D' i'ameter ---------------- Number ----------------------- Rock Filled Yes ❑ No .0 <br /> �th, <br /> Water abl i ------_.---.-_.Rcick Size ---------i-----------_--------- <br /> ----------- --------- <br /> Irfam to neartst;k W-ell ------------Foundation ----- -------------- Prop. Line _.. <br /> REPAIR/ADDITIOI1(Prev. SonitationNRermi4i 1 -=--------------------------- --------- Dbte --------------- <br /> X <br /> ------------------- ,..--------------------------- <br /> Dis osal <br /> ire 1�-—-------------------------------------------- <br /> J <br /> p I y e uirementsld?,�_ ------- --- ----- --- <br /> Disposal Fiel <br /> ---- - -------- - --- ---------------------w <br /> ----- - --- --- <br /> _Wj��r �u�irecl addition on <br /> (Draw existing a rever re /e) <br /> I hereby certify that I have prepared tiIii a 1011cation and that -the-o-Workrwill be done in accordance with Son Joaquin <br /> County Ordinance Slate Laws, and Rules and Regulations of the San Joac'Un`ilLocal Health bistrict. Home owner or licen- <br /> sed agents signatullre certifies the following: <br /> "I certify that in thb-performante of thelwork for which this permit is issued, I shall not employ in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - ------- ------- ----- - .......m-------------- ------------------==-Owner <br /> ---------------------------- <br /> T e ------------- ------- <br /> By ------- ------------ ------------- <br /> (jif other n owner} <br /> FOR DkPAXTM9_NTtUSE ONLY <br /> ,F <br /> APPLICATION ACCEPTED BY -- -------1.:W -------------------------------------DAT ---��14101iq�-----------_-_--- <br /> - ------------ --------I-------------------- <br /> BUILDINGPERMITf' ISSUED ------- -------------�J-------------------- ----------------------------------------------/��_ DWT E ------------------------ ---------------- <br /> ADDITIONALCOMMENTS -------------------------- -------- ------- - - -------------------- r------------------- ------------------------------------------- <br /> ---------- -- - ----- <br /> --------------------------/;� *g ---------- <br /> ---------- ------------------------ <br /> -4--- --------- ---- V ----------------------- <br /> 41--- ----------------------------V---------- ---------------------- ----------------------- <br /> - ---- --- --------- - ------ <br /> ------------------- ----------------------------------------------- <br /> ----------------------------- - ---------------- --- ---- - - ---- -- -- --- --- -- -- <br /> Final Inspection b <br /> ----------------------------------------------- aie ---1 <br /> Q ----------- <br /> SAN J0AQUIW)1L%6CAL HEALTH DISTRICT <br /> E. H. 9,4� 1-'68 Rev. 5M <br />