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FOR OFFICE USE: <br /> C _ g APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> ----------------- -- <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 /> - - , -,-- _-�. -- �_ _ <br /> .,_ _ ---- <br /> _--- r <br /> JOB ADDRESS/LOC --CENSUS TRACT ----------------•----- <br /> Owner's Name " <br /> �a .._� h'C�f =' �� -- z /°'l = -------------------Phone <br /> I Address ---, , l -- /f1_�'7 Cit -. _��rd �------------------------ ------- <br /> ff <br /> Contractor's Name _1+ --------------- -------------------------- #i4YI;.11------ Phone-,�,��`��E_��_ <br /> Installation will serve: Residence�Apartment House,C7 Commercial :❑Trailer Court 0I Motel ❑ Other ------------ ------------------------------ <br /> Number of living units:---!-___._ Number of !bedrooms -------Garbage Grinder P Lot Size 1,0 _x - - ........ <br /> Water Supply: Public System and name ----AX(fl .f---- E,;=-,f •---------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam '❑ Clay Loam;❑ <br /> Hardpan ❑ 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.) N�; <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) tVi <br /> iu <br /> PACKAGE TREATMENT [ SEPTIC TANK [Pc Size __,J ,- _______ LiquiP Depth <br /> rr � � <br /> Capacity _ .__ Type?/v, -�_"_L'-__ Material�r,/;It4__°_____ No.fCom artments -- <br /> Distance to nearest: Well __ __ <br /> ----���-----..Foundation _.A?------ -- --- Prop. Line _J-------- <br /> LEACHING LINE V4" No. of .Lines �' g ;:_11.12� f ` <br /> ------�-------------- Length of each line----- Total Length .,f.��_..--•---•__-- <br /> D' Box �/ ,a_ Type Filter Material f fC epth Filter Material �e�K______________________._---... <br /> .. <br /> Distance to nearest: Well -_/ � -_ Foundation ------------- Property Line <br /> SEEPAGE PIT [ j Depth �?..- __.________ Diameter 7 .- Number __-, —------------------ Rock Filled Yes No C] i <br /> p r /_r <br /> Water Table Depth -----��- - -- -------------------=-----Rock Size --....- -------------•---- <br /> Distance to nearest: Well '.- ---------------------Foundation -__l'-A_f----.Prop. Line -------------- ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date ---------------------------------- ,t <br /> Septic Tank (Specify Requirements) ---- -------------------------------------------------- ----------------------------- <br /> .. <br /> Disposal Field (Specify Requirements) -------------------------------•------------------ ------------------------------------- --------------------------- <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 Son 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 /> _ F <br /> BY --------------------------- --------------- Title ------- --_-------------------- <br /> f other than owner) ,/` - y <br /> FOR DEPARTMENT USE ONLY <br /> E <br /> APPLICATION ACCEPTED BY f DATE rb I <br /> BUILDINGPERMIT ISSUED ------------- ------ ------ ---------- ----------------- -------------------------------=--------------DATE -------------------------- <br /> ADDITIONAL COMMENTS -- <br /> -------------------------------------------------------------=--------------------------- ! <br /> -------------------- ----- ------------------------- -- --------------------------------------- -------------------------- <br /> ----- -------------------------- <br /> ----- <br /> 0 ill -- ----------------------------------------------------------------------------------- <br /> Final Insy:b <br /> %­ <br /> p <br /> Y� -- ----- - ----•-------------- - -- -------------------------- --------- ----------------.bate - � �--------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />