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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------ ------- Permit No. <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued 4_ _ ___Z�- <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 o. 549 and.existing Rules and Regulations. <br /> Aj <br /> JOB ADDRESS/LO�N _ �/ , ______ _ - -_- <br /> ------ - - ------------- -----------CENSUS TRACT -------------- ----------- <br /> Owner's Name �._ �� ._ _ y - 5U - - --'------ -- - --------•-----•------------- City _ - --- - - ------Phone -- - -1-^--------Y--Y•-•- <br /> T >` <br /> Address �.y - ------------ -------- <br /> Contractor's Name ------- -.- ,- --- - ----------- ---------------.License # -`�rrT-�---- Phone <br /> Installation will serve: iResidence ❑Apartment House❑ Commercial Mrailer Court i❑ <br /> Motel ❑Other ---- ------------------------------------- <br /> Number of living units:_----------- Number of bedrooms ____________Garbage Grinder ------------ 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 ❑ <br /> Hardpan ❑ Adobe ' Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <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 public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK;[ Size__ �Q21� `5x r- Liquid bepth -------------------------- LA <br /> Yp P /-?4► ______ No. Compartments _____ ___ __ <br /> Capacity ��7:�_Q_______- T e 11tCA _______ Material- <br /> Distance to nearest. Well -___=___-___Foundation __.3_Q__- _-_- -Prop. Line <br /> G LINE No, of Lines ' <br /> ;p� ------- ------------- Length of each line___--�4_�--_-- ------ Total Length -----`�U___•--......_--- <br /> LEACHING � <br /> 'D' Box ------------ Type Filter Material __A4 '___Depth Filter Material __.__-_t _____________________________ <br /> 1 <br /> ' Distance to nearest: Well _16.4--_______-__-- Foundation _&_0--------------- Property: Line "_'__ ------------- <br /> SEEPAGE <br /> -----------_SEEPAGE PIT [ Depth _,P_2.S_-__----- Diameter! Z� _„____ Number ----------- ____ _____ Rock Filled Yes ' No 0 <br /> f Water Table Depth ---,/d____'------------------- ------- -Rock Size c2XI <br /> Distance to nearest: Well __,, Q_ ?_______________ ______Foundation ---------- Prop: . 'Line _4�................ <br /> } <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------- ___!__.__._______) <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------ -•----------------------------------------------------------------------------------------------------- <br /> _____________________________________________________3-______________________________-_____________-___________-__________--________._____._____________.________________________.________________________ <br /> _____________________________________________________f_.___.____________-_-___________._ ____________________-_____________________--____-_______.________________.___-______---_____.____________________ <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 San Joaquin Local Health District. Home owner or [icon- <br /> sed agents signature certifies the following: i - u - -- •. <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 bec e s bject to or an's Comp" tion laws of California." <br /> Signed GU ----------"I Owner <br /> BY ------------------------------ ----------------- - .C - '' Title ---- ---------------------------- ------------------------- ------------ <br /> (If other than owner a <br /> a <br /> EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .------- a.. _ .. ---- ----------------- DATE ------ "l -------------- <br /> BUILDING PERMIT ISSUED --------- -- .------ - -------- <br /> --'�� ------------=--------------DATE ---------------------------------- <br /> A DITIONAL COMME TS __.___ - 3 <br /> _ ----------------------------------------•------- <br /> --------------- <br /> --------------------- <br /> - <br /> ----------------------------- ---- t <br /> -------------------- -------------- -------=--------a------------------------------------ ---- ---------- <br /> -------------------------------------- ------------ <br /> --=- ------------------- <br /> ----------------------------------Date _-_-Final Inspection by SA�QUIN LOCAL HEALTH DISTRICT <br /> r <br />