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FOR OFFICE USE: <br /> APPLICATION FOR SANITA7lON PERMIT S <br />' �_ /11..'_ !1 Permit No. <br /> --------- <br /> (Complete in Triplicate) , <br /> Date Issued ':r2111--6 <br /> This Permit Expires 1 Year From Date Issued <br /> --------------- ------ ----- h <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 /> �- I <br /> -------------------------- <br /> �f - ------CENSUS TRACT <br /> JOB ADDRESS/LOCATION .=--d--- - ---- -, --- <br /> ----------- ---------------------------- --Phone ----------------------------------- <br /> Owner's Name __ - - - --- - -------- -=--------- -----•=-- ...-•---- �. <br /> Git <br /> Address ----- ---------- -Q3! -------- -- Y _ _-- <br /> =- <br /> Contractor's Nam S- _ --.License # ------------------------ Phone ------- ---------•• <br /> ------- ----------------------------------------- - -- - - <br /> Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ______ - <br /> -- - <br /> Number of living units:... _ <br /> - _ Number ofbedrooms ftA-- ----------- ----------- ----- - - <br /> i------Garbage Grinder int----- Lot Size --------------- <br /> Water Supply: Public System and name------------------------------! . -----------------------------------------•---------Private <br /> - ------------------------- <br /> Character of soil to a depth of 3 feet Sand'❑ Silt ❑ j Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe��EP­ ll 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ } E Size------------------------------------------------ Liquid Depth ---------------------.----- <br /> v <br /> i -------------------_- <br /> Distance <br /> {� <br /> � Capacity ----- ---- ----- Type -------------------- Material------------ ------- No. Compartments -----------------.-•-- <br /> .I -------Foundation ---------------------- Prop. Line ---------- ------ L' <br /> pistance to nearest: Well ____--------------------.--- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length :-------------- ------ <br /> 'D' Box ------------ Type Filter Material ---------- ---Depth Filter Material ------------------------ <br /> Distance to nearest: Well ----------------------- Foundation Property Line ____-_-____--___-_.__.__ <br /> - Rock Filled Yes No 0 <br /> SEEPAGE PIT [ ] Depth --- Diameter ----------------- Number --------------------------- 0 <br /> Water Table Depth ---------- ----------------- Rock Size <br /> l <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------ --------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------- --- Date ---------------------------------- <br /> Septic Tank (Specify Requirements) ------------ ----t--- <br /> ------- ----- ----------------------------------------------------------- <br /> I( <br /> ------------------------------------- ----c- <br /> -----------. <br /> X �` <br /> Disposal Field {Specify Requirements} ------ ------ ----- - - -..-_ <br /> ---- <br /> lil <br /> ---------------------------------------------------------------- <br /> -----------------•--------- <br /> E <br /> �. ---------- ------------------ -------------------- <br /> --------------- ------------------------------------------------------------------------ --- ----------------------- <br /> j (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 iicen- <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 subject to Workman"s Compensation laws of California." <br /> Signed -- I1-[ ________ Owner <br /> - ----------------------------------------- - ----------------------------- -------- <br /> BY _ r -------------------------------I----- <br /> Title --------------- --- --------------------------- ----------------------- <br /> » If other than owner} ` <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -W-1_--'--`----- <br /> ------. .�------------- ----- DATE - <br /> BUILDING PERMIT ISSUED ------- ------------- -------------------------- DATE <br /> ADDITIONAL COMMENTS ---------------- <br /> ----------------------------- <br /> ------------------- ----------------- ---------------------------------------------------- -)------------------------- <br /> ------------------ ---------------- ---------------------------------------------- ---------i------------------------ -------- - <br /> --------- <br /> --- e <br /> - - <br /> !I -------Date �_ -,�5-- -- -- -'----- ------- <br /> Final Ins ection b _.�-'---�.�--- --------------------------------------- <br /> SAN JOAQUIN` LOCAL HEALTH DISTRICT <br /> I <br /> E. H. 9 1-'`b8 Rev. 5M <br />