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FOR40FFIdt USE: APPLICATION FOR SANITATION PERMIT _� 3 <br /> -----------------------------------•-------------------- <br /> Permit No. - --------------. <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- . _ Date Issued -__--�`��- Y <br /> - --------------- /7,7ThIs Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 --------- '?Q_-t-------- -------- - ---------------- ---------------CENSUS TRACT ----- ------ ---- <br /> Owner's Name ----------- ------Phone ----- <br /> Address ------------- ------------- 9-1----------AQ p `----------------------------- --•--- City ---------- ,1er4--------------------------------------•, <br /> - <br /> Contractor's Name f'! EdA-� --------------- --------License # �-J` .� Phone <br /> / <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court l❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder __--_-____.-=-y Lot Size _._____--_"_______.__---------------•---- <br /> Water Supply: Public System and name ------------------------------------------------------------------------ ------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------- ------ a <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 seepa pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size---�:__ --.�-------`---------- Liquid Depth ----- ----------- <br /> Capacity ---/d--tlO----- Type f/n"t_ -CaT1 Material____ No. Compartments --'-�?---------------- <br /> ' --------L7-- ----------------Foundation l� Prop. Line __�- ------------ <br /> Distance to nearest: Well <br /> LEACHING LINE No, of Lines --_-____ ------ Length Length of each line___-.____°7U___-_.______ Total Length :,PVa---------------- <br />' 'D'" Box __ _-____-- ype Filter Mafierial --_-- _Depth Filter Material -------------------------------------- ------( y � T p <br /> Distance to nearest: Well ---------- Foundation ---ff)-------------- Property Line _L:5___1------------- <br /> SEEPAGE PIT [ ] Depth :� --------- Diameter _______________ Number -------- ------------------- Rock Filled Yes ❑ No I❑ <br /> i <br /> Water Table Depth - --------------------------------------------Rock Size ------- ----------------- ------ <br /> Distance to nearest: Weill--_---- --------------- ----------------- Prop. Line ---------------------- <br /> r REPAIR/ADDITION(Prev. Sanitation Permit# �--------------------�------------- .-----'Date- ------------.- ---} <br /> r l <br /> Septic'Tank (Specify Requirements) ---- -- -------------------------------- <br /> - ------------------------------------ -----------<..--------------------------- <br /> - - <br /> Disposal Field (Specify Requirements) ---------------------------•------------------------------------------------------- ---- -------------------------------------------- <br /> --------------------------------------------------------------- - <br /> t ------- ----------------- ------------------------ ----------------- <br /> l ------------------------------ <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'Son-:loaquin Local Health District. Home owner or licen. <br /> sed agents signature certifies the following: 1 ' <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 s sect to orkm n's Co nsdt€ laws of California." <br /> Owner <br /> Signed -�--- ��-'`�-------- -------------- r <br /> ------------------------ Title ----------- ------------------------------------- -------------- ------ <br /> By <br /> (If other than owner) .1 <br /> --�� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------1--' `©-------------------------- - - -------. DATE.------ 'l'—-7------ <br /> -- - -------------------------------- - <br /> ._.,. d _ _ � -----------------DATE .._------'--------- <br /> BUILDING PERMIT ISSUED __________________`" -- - -"--"--"--"- ""-"---"- <br /> ---------------------------------------------------- - - <br /> ADDITIONAL COMMENTS - ------ ----- -- -- ---------------------- --------------------------- <br /> - --------------------------------------- --- ------------------------------------- <br /> -------------------------- ---------------- -- -- ---- --- ----------------------- - ----- -- - ----- ------------------------------ ---------------------------------------- -- --- - ----------------------------------------------------- ----------------------------- <br /> ---------------------- <br /> - l <br /> --------------------------------------------- - ----- - - - - ------------------------------------------ <br /> Final Inspection ---Date ------- <br /> --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y►+, <br /> I E. H. 9 1-'68 Rev. 5M C`0 <br />