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iE <br /> . FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -' <br /> ----------------------------------------------- <br /> Permit No: <br /> ` (Complete in Triplicate) <br /> Date Issued <br /> :---_------ ------- -------- This Permit Expires 1 Year From Date Issued h <br /> Appl ci ation 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 ADD <br /> RESS/LOCATI '_____ _ -- - i1�_ _= ±" ------� - -- CENSUS .TRACT --•--____-- <br /> ------------------------------ - -------------------Phone •--- .. <br /> Owner's Name --.-___C <br /> �_ kms _ II <br /> . -------- City - -----Address --------- ------ ------------------------------ <br /> 7 <br /> Contractor's Name -------------- -----------------------------------------==-------.License # ---------;-------------- Phone ------------------------------ <br /> Installation <br /> ------------------- ---r- <br /> --- <br /> Installation will serve: Residence J Apartment House❑ Commercial :❑Trailer Court ',❑ II <br /> Motel ❑Other ___ ----------------------------------- <br /> , <br /> Number of living units:---/------ Number of bedrooms __-------Garba-ge Grinder _ tot Size ----- _ __ <br /> li <br /> Water Supply: Public System and name ----------------------------------------------------------------------------------------------•----------------Private , <br /> 1 II <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.t <br /> ` Hardpan dobe EJ' Fill Material If yes, type ____________________________ <br /> A <br /> (Plot plan, ,showing size of lot, location of system-in relation to wells, buildings, etc: must be placed on reverse side.) <br /> ,I <br /> NEW INSTALLATION: {No septic flank or seepage pit permitted if public sewer is available within 200 feet,) Ip <br /> Y. <br /> PACKAGE TREATMENT [ I SEPTIC TANK: Size___� ____ ._- - - ---- ----------- ' ---------------- <br /> Capacity <br /> ' � �' -- ---- Liquid Depth --�- - ----------------- <br /> Capacity ----,-- Type "./"'--- � Material-- r>........... No. Compartments <br /> Distance ,to nearest- Well ___ ' t __________________Foundation __ " ------------- Prop. Line .` _____:__.I..._ <br /> -------------------- Length of ch line--- ----.-------- Length _ <br /> LEACHING LINE ( � No. of Lines g ----- Total Len �____________I�___. � <br /> _ 1&11# <br /> ' 'D' Box - Type Filter Material __ Depth th -Filter Material - -------------•-----••--•--------��... t <br /> `ff <br /> is <br /> Distance o nearest: Well �._ __�____;_,_ Foundation __-___________ Property Line _____________._.h... <br /> lJ s ., -- -------- !. <br /> [ � Depth __*J.1 -_____- Dianae�ter �-"�' ` Number � ___ Rock Filled Yes�'gf No i❑ <br /> Water Table Depth --- - ------------------------------------Rock Size ---_ _------------------------- <br /> Distance <br /> --------------_ - i <br /> ' ___Foundation p. <br /> � Distance to nearest: Well __��+-_ar__g _______'__:__._____ +�`��--- -_--- Pro Line _______________ <br /> IF <br /> REPAIR/ADDITION(Prev. Sanitation Permit#_ _---------------------------------------------Date ---------------------------- <br /> Septic Tank (Specif Reuirenents) ---------------- 1 � Ii�.._ <br /> Disposal <br /> - <br /> Field (Specify Requirements) ---------------------------------------------------------------------- -------=--------------------------------------•----------II = <br /> =x <br /> 'i <br /> ---------------------- '------------------- ---------------------------------------------------------------------------------------------- ' <br /> ;* {Drhw existing and required addition on reverse side) _ I <br /> t I hereby certify that I'Have prepared"'this application qnd that the work will be done 'in accordance with San Joaquin Y � <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 /> t "i certify that in the performonce of the work for wh- this permit is issued, I shall not employ any person in such manner <br /> l as to beco subject toW rkrn Al,Ca p ' sation aws f California." <br /> Signed ,.- f i ------- Owner �� <br /> BY ----------------------------------- ------------------ _ Jitle._- <br /> -------------------------------- ------ --------------- <br /> [If other than owner) <br /> I! <br /> FOR DEPARTMENT USE ONLY <br /> u <br /> n 'r, n-y,,,,,, -- ------------------ <br /> I APPLICATION ACCEPTED BY ------ '_. - ---- ---------------------- DATE _.! `" <br /> BUILDING PERMIT ISSUED --------------------------------------------------------------- <br /> --- ------------- ----------------------- ------------------------DATE ----------------------- <br /> i <br /> ADDITIONAL COMMENTS ------ ------------------------------------------ -------------------------------=---------------------------------------- ----------------- ---- <br /> 2 <br /> --------------------------------------------------------5--------------------------------_------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------- <br /> L <br /> - <br /> Final Inspection by: ....... z- <br /> w - ;< -------------------------- --------- ---------------------Date ------- -` -----------------' <br /> r <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, Is <br />