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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ./ <br /> ............._ .................... .........--....---...... <br /> ..... (Complete in Triplicate) Permit No. f.::_ <br /> ................ ..... .............. w q ; <br />............................ ........ .. .... .. ........ This Permit Expires l Year From Date Issued Date Issued <br /> i <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 /> JOB ADDRESS/LOCATION I.0I. - -Qa--. -- , !F <br /> Owner's Name _.......... Cy <br /> - -- ---- . .. . . ......... ........ .......CENSUS TRACT <br /> Address .. ................• ...0 ...... City _... <br /> Contractor's Name .. .... .... . .. ... -------.......License # .......... Phone .............................. <br /> Installation will serve: Residence ❑ Apartment Ho Commercial ❑Trailer Court 0 <br /> Motel ❑Other . ..... .. ....... ...... G�1y1!t► <br /> Number of living units: . 3._.. . Number of bedrooms .......----.Garbage Grinder ............ Lot Size ...... ~4Z.;k�­ -_--�...... <br /> Water Supply: Public System and name ................. --------------------------------- --- ......---..........................Private [] <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Cloy ❑ Peat❑ Sandy Loom ❑ Clay Loam �► <br /> Hardpan ❑ Adobe ❑ Fill Material ...... .. .. If yes,type K- --- <br /> Mot 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 /> J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.[ Size....................._-------_._-_...._,....._ . Liquid Depth .......................... <br /> Capacity Type .................... Material....... . - No. Compartments .................0 <br /> Distance to nearest: Well --------:---Foundation ...................... Prop. Line --..-------------.._� i <br /> O ! <br /> LEACHING LINE [ } No. of Lines Length of each line ........ Total Length ----------------------------O i <br /> 'D' Box .- .. Type Filter Material --------------------Depth Filter Material ............................................ <br /> Distance to nearest. Well ........................ Foundation ... .................. Property Line ........................ <br /> SEEPAGE PIT [ ) Depth . Diameter ................ Number Rock Filled Yes ❑ No ❑` <br /> Water Table Depth ----------- ....................................Rock Size .................... ----------- <br /> Distance <br /> -- ------Distance to nearest: Well -_-_-_Foundation ...... Prop. line .....................� 1 <br /> REPAIR/ADDITION IPrev. Sanitation Permit 5# ........ ............. ..................... Date _._.__..-_._.___..__.________..___) I <br /> Septic Tank (Specify Requirements) . --------- �- ------ --------------------•-•---_----+------ ... /.j... ....._............._.-------- t <br /> Disposal Field (Specify Requirements) -- <br /> --- - - -.- . 4----------------_0..�..1-. -- .�.I��.C•1T <br /> ......... --------------- -- ........ ------- -­ ....... .................................. . ...... <br /> IDraw existing and required addition an 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 sub[ec to Wo man"=mns on laws of California." <br /> Signed _ �...... - ---- Owner <br /> By . .•-- ----- ........ - - Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..... .. -. DATE . . S. -.,7'Y ------------ <br /> BUILDING PERMIT ISSUED - ..... ...... . . ......... .... . ................... .DATE . .............. ............. <br /> ADDITIONAL COMMENTS .. . . .......... ..---.-------------- ......-------- <br /> ..-- ------------ ------- <br /> -- ---.._.-.---.... -----.------------ - ------- --- ------ j ..... <br /> Final Inspection by: ..__. . ---Date ..�•. ��- _ ... <br /> S N OAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 13 24 1-'68 Pv. 7172 3 M <br />