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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---�-- � Permit No: -- <br /> (Complete in Triplicate) <br /> ----- -- <br /> 11U�---------- <br /> - - i- - Date Issued <br /> ---------------- This Permit Expires ] 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. 54,9 od existing Rules and Regulations: <br /> JOS ADDRESS/LOCATION`"` 4y CENSUS TRACT <br /> Owner's Name --------- Phone 7 r°' 1 .. <br /> Address -------------------- ®• �] ---- -��-�--------------- city <br /> r <br /> Contractor's Name -------- ^ .License # -1 CJa.SLI Phone � p�67 <br /> Installation will serve: Residence [] Apartment House-E] Commercial railer Court i❑ <br /> . .._ ,Motel ❑ Other -------------------- <br /> S <br /> Number of living units------------- Number of bedrooms i_-:_--:-_--Gararbage Grinder ............ Lot Size ---- -------------------- <br /> Water Supply: Public System and name -------------- `--' Private <br /> - - -- --- El <br /> of soil to a depth of 3 feet: Sand'❑ Sitt'`E] ` `Clay,❑ Peat❑ Sandy Loam -❑ Clay Loam E] <br /> Hardpan E] 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,) <br /> k '' <br /> PACKAGE TREATMENT { I SEPTIC TANK;[ ] ) Size--------------------------- '------------- Liquid Depth --------------- ----------- <br /> rL %.;'141 <br /> Capacity ---- ---- ---------- Type -------------------- Material--------*-------------- <br /> No. Compartments ------•................ <br /> Distance to nearest: Well ------------------------------------Found n ------------- -------- Prop. Line ---------------7...... <br /> LEACHING LINE [ ] No. of Lines,) #---:-:------$-------- <br /> Length of each line--`-`--_--__-__----_---_ Tota_ I Length --------------- - - ---- -'D' Box .- ------ Type Filter Material --------------------Depth�Filterl4 Material -------- '-------------- ---------- , + <br /> j <br /> Distance to nearest: Well ------------------------ Foundation------------------------ Property Line ------------------------ <br /> SEEPAGE <br /> __---SEEPAGE PIT [ ]: Depth -------------------- Diameter ----------------Number --------.------------------- Rock Filled Yes ❑ No CIF <br /> Water Table Depth -----""------ ---Rock Size -------------------------------- . <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line\- ------ <br /> 0 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --__--------_-__----_--___-_--_---} <br /> Septic Tank (Specify Requirements) ---------------- * -------- ---- ---------- ---------------- <br /> ------------------------- <br /> Disposal <br /> --•--- <br /> ----------------------- <br /> Disposal Field• (Specify Requirements) ---_-- <br /> •s7 <br /> fX `- --------- ------I¢------ ��--__----- ----------------------=------ --------------- <br /> -------- <br /> --- -------------------------- - ------------------------------------------------------------------------------------ -------- <br /> {Draw existing and required <br /> ------------=----------- -------- <br /> ' 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 ------ - -- --------- --` - <br /> a4K--------------------------------- Title ........ � /I <br /> {if othe an owner) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- <br /> --------------------------------------------------------------- DATE --z.- = ----•------------------- <br /> BUILDING PERMIT ISSUED --- -- DATE ------------------------------------------- <br /> ----------------------------------------------------------------- <br /> ADDITIONAL COMMENTS ---- - ---- ----------------------------------- = <br /> ----------------------------------------------- - ---� ____ ___.___�---T:::a�__:=__ z �/ �______:_ _____:__::______- _--- -:__:__::________:_____:___._______--- <br /> -- - - --------------------------- <br /> - - - - - - - - - --------------------------------------------------------------------------- -- --- -- ------- --- -- <br /> Final Inspection by: --------- - -� C Date - �l f.7/ ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />