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. „._ .FOR-OFFICE USE: <br /> APPLICATION FOR'SANITATION `PERMIT <br /> fi(°� �'�t� Permit No: -- _ <br /> 4 � (Complete in Triplicate) ; <br /> ------------------------------------------------------- d _/ <br /> Date Issued l '_-- &f <br /> -------- -------------------------------- This Permit Expires ] Year From Date Issued <br /> Application is hereby made to the San Joaquin Local WealthTDistrict for a permit to construct"dridinsfi ll�'#Fie work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules�and-'Rfgvlatlons: t <br /> JOB ADDRESS/LOC N . = # - - _CENS S.TRACT-- -------�.:... <br /> --•----------------------f---------_- -------Phone---------� ------------------------- <br /> Owner's Name -�' - ��---�-- ----- ------ - I <br /> Address -_�------- ----- - - - - -- - - ---- -- ---------—--------•--. City -- �pjGG <br /> � �" � � ------ ------------------- -- ----------License # �df - Phone------------------------------------------_-------------- <br /> - <br /> Contractor's Name -----£/�.:..�,� --_ ..__ <br /> Installation will serve: Residence [Apartment House,❑ Commercial []Trailer Court ;❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units----/------ Number of bedrooms _cZ---.Garbage Grinder ------------ Lot Size ---------------- <br /> Water Supply: Public System and name ____________________ ________-__i---_Private [. <br /> Character of soil to a depth of 3 feet: Sand❑ t❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay ILoam fl I <br /> I <br /> Hardpan Ze Adobe ❑ Fill Material _'----------- if yes, type _______________r ._________ { <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placejd on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 2001feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size--------------------------------I--------------- Liquid Depth ---------------- <br /> Capacity <br /> --------------Capacity ----- -------------- Type,.-------------------- Material ------- ------------ No. Compartments -----------------_.... i <br /> Distance to nearest: Well -----------------------------------Foundation ---------------------- Prop. Line ---.------------•----- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_t-------------------_--___ Total Length _---__-____-____--_-________ <br /> 'D' Box ------------ Type Filter MatericE! ---.-----------------Depth Filter Material --------------------.----------------•------ <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ________-___-_-___._-___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----:- ----- ------ Rock Filled-TM, esY❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------------- <br /> Distance <br /> -____.__---____________--Distance to nearest: Well ----------------------------------------Foundation -.------------------ Prop Line ....%__............ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ----------____---__-__ _______--__� { <br /> Septic Tank {Specify Requirements) ------------------- --------------- ------ ---------- - ----� ------- <br /> (Specify ---- <br /> Disposa Field (Specify Requirements) --- -'-- --��--- � :- - - - - - - =_- --� ----- ------ - - <br /> - ----------------------- ----r--------------------------------- ±------------------ <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,6e tlone 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 /> "1 certify that in the performance of the work for which this permit islssued, 1 shall inot employ any person in such manner <br /> as to become subject t rkman's C m so i laws of California." �� f <br /> Signed - ------- -------- - --------------- Owner <br /> ------------ - <br /> By -------------------------------- Title c "^' ---- <br /> (If other than owner) I �� <br /> FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - --- ----------------------------------------- <br /> ---- - - - - - - '--------- DATE 14!----- - -------------- ---------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------- --------------------------------------=-- -----------DATE ------------------------------------------- <br /> -A--D---D--I-T--I--O------N----A----L- <br /> COMMENTTS ------------------ ' - ------ _ <br /> -- ----- - - - ----- -- <br /> ------ - -------------- ---------------------- ---------------------------------------.----------------------------------------------- <br /> ----------------------------- - -- ----------- ------- _ 5 -------------- <br /> Final Inspection by. ------------------------Date --- ----------- -- <br /> M., <br /> el-d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'6$ Rev. 5M <br />