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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------__­------ ------------ (Complete in Triplicate) Permit No. <br /> -----------------------------------------:--------------- This Permit Expires-1 Year From Date Issued Date Issued <br /> _�_iVher'b� madi' Fo--the San Joaq_uin_'Lo_ca_l' ;Ifli Disfria for a permit to'construct and install the work herein <br /> Application e e He <br /> described. This application is made in compliance with County,Ordinance No. 549 and existing Rules and Regulations: <br /> JOBADDRESS/LOCATION ---------------------------------------------------------------------1--------.__ ---CENSUS TRACT --_-__--__-___-_____------ <br /> Owner's Name -------------------------------- -----Phone ----- ------------------------------ <br /> Address ------------------- 64-k-- 63-6------------------------------------- <br /> City ... - ------------------------------------------ --------- <br /> ------------------------ Phone ---------------------_------ <br /> Contractor's Name ----------------License # <br /> Installation will serve: Residence eApartment House,E] Commercial :F­lTrailer Court ;E] <br /> I Motel F--l Other -------------------------------------------- <br /> Number of living units.--,--.-/--- Number of bedrooms _:��-----Garba-ge'Grinder ------------ Lot Size ----------------- -------------------------- <br /> Water Supply: Public System and name ---------------------------------••-------------------------- ------------------------------------------------Private <br /> Character of soil to a depth of 3 feet. Sand'o Silt Clay 0 Peat E] Sandy Loom EJ Clay Loam .[71 <br /> Hardpan W 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 /> PACKAGE TREATMENT, SEPTIC TANK'[ Sizer_--- -- -------------------------------------- Liquid Depth ----------- --------------- <br /> Capacity' ----- -------------- Type -------------------- Material- -------------------- No. Compartments ---------------------- Ilk 11 <br /> Distonce' to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE No. of Lines ------------------ ----- Length of each line____________________.._.___ Total Length ----------------_--------- <br /> IN <br /> �'t , <br /> ' 'D' Box ------ -- Type Filter Material --------------------Depth Filter Material -------------------- ----------------------- <br /> Distance to nearest: Well ------------------------ Foundation ---------------------- - Property Line ._______:___-_____-.--- <br /> SEEPAGE <br /> --------;-------------- <br /> SEEPAGE PIT Depth ---- ---------------- Diameter, ---------------- Number --------- ------------------- Rock Filled Yes EJ No 0 <br /> Water Table Depth ------- ---------------I-------- -------Rock Size -------------------------------- <br /> Distance to nearest: Well __________________________________-___Foundation ---- --------------- Prop. Line _____---______-______ <br /> REPAIR/ADDITION(Prev. Sanitation Permit#.________.._______________________________._ Date _______-_____.___________________-) <br /> Septic Tank (Specify Requirements) ------=-------------- -----I----------------------------------------------------------------------------------------11------------------ -------- <br /> Disposal Field (Specify Requirements) -------- -------- -- ----------- <br /> ---------- ----------------------------------------------------------------------------------------- ---- <br /> r ___ f I i <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 /> ------------------ --- <br /> By ------------------ __other-. - __than-an Za-le-111y----------- Title ----9-&-___1.�_ --- -------------------- ---------------- <br /> (if <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �_ �------------------------------------------------------. DATE <br /> ------------- <br /> BUILDING PERMIT ISSUED ------------------------- ------------------------------------------------------------ --------- -----_-DATE --------------------------- ------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------------------- -------------- <br /> ­ ------- ----------------------------------------------------------------------------------------------------------------------------------------I-------- ----------------------------------- -------- <br /> ------------------------------ ------------------------ --------------------------------------------------- -------------------------------------------------------------- ----------- <br /> ------------------------------- --------------------7---------------------------------------------------------------------------�y---2_� <br /> ------------------------------------------------------------ --Date ---- --------------- ----- ------- <br /> Final Inspection by- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />