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FOR`OFFICE USE: <br /> i <br /> � ) APPLICATION FOR SANITATION PERMIT _ <br /> ��. --- ----- `s--"`.fir Permit No. 7L <br /> Q (� <br /> ' (Complete in Triplicate) <br /> -----------------_-_---------- This Permit Expires i Year From Date Issued Date Issued _._____ ___--.__. <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 ------- � -_5---- ---------------------------- -- -----CENSUS TRACT ---------- ---- - <br /> ROwner's Name ._� / ----------RA Phone <br /> Address -------------------- City ----'AWZj714----------------------�-----------------•------ <br /> Contractor's Name -------- ---------------------------------License # �J_jJ ... Phone _sr< - <br /> ' Installation will serve: Residence -] Apartment House❑ Commercial : filer Court i❑ <br /> Motel ❑ Other ------------ ---- ------------------------- ! <br /> f - <br /> Number of living units;---- Number of bedrooms --_________Garbage Grinder ------------ Lot Size j;7y—//7---,j ` `Y� <br /> �; -------- -------------------- <br /> Water Supply: Public System and name ------�AItTy------ er- --------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay F] Peat ElSandy Loam ❑ Clay Loam;C7 <br /> Hardpan E] Adobe ill Material -------____ If yes,type _____.______-____--__-__ <br /> F <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 pubic sewer is <br /> available within 200 feet,) � , <br /> PACKAGE TREATMENT { SEPTIC TANK Size____ ��--- ---------------------- Liquid Depth _____67�_______-.:-- W <br /> Capacity.:A0_0------ Type -0PR97_G°4-'qMaterial---------------------- No. rCompartments ----- = {� <br /> Distance :to nearest: Well -----------------_-----------------_Foundation -_1__-_______ Prop. Line ----;5 : :_______- ) <br /> LEACHING LINE [ ] No. of Lines --------j------------- Length of each line-------VU------------- Total Length --------------- R <br /> 'D' Box .__./------ Type Filter Material Depth Filter Material __ �l�______.____.....___:`_.-.._. <br /> Distance ,to nearest: Well ---- ------------------- Foundation ------------------------ Property Line ______________-__._.___ <br /> --___ Number Rock Filled Yes No <br /> SEEPAGI: PIT [ ] Depth ---'----------------- Diameter ---------- ---------------------------- 0 C <br /> ' Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well _._______-____________________________Foundation --- ----------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------.----------} <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- <br /> i Disposal Field (Specify Requirements) ------------------ -------------- ------------------------ ------------ ------------------------------------•----------- <br /> =N'�------------------------------------------- ---------------------------------------=--------------•--------- <br /> ir ------ <br /> ` (Draw.,existing ancfre-quired 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 Ordinancesr State Laws; and Rules`land;RegulQtions 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 whic�s permit is issued, I shall not employ any person in such manner <br /> as to become sub'ec o Workman's C pensation laws of California." <br /> ---- <br /> Signed ------- ------------------------------ Owner <br /> By ----- --------- ----------------------------------------------------- --------------------------- Title ------------------------- -------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ------ -------------------------------- DATE --------6 <br /> ---- _ -6� <br /> BUILDINGPERMIT ISSUED ----------- -------------------------------- ------------ ----------------------------------------------DATE ------ ----•----------------------------- <br /> ADDITIONALCOMMENTS -------------------------- --------------------------------------------------- ---------------------------------------------------=--------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------- --- -------- -- - --------------- -------------- ---fL_-:.-.--- --------------------------------- ---------------------------------------- <br /> Final Inspection by: ------------------------------------•----------- -------------------- Date -/1�= 5' <br /> �i <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> y E. H. 9 1-'a8 R M <br />