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FOR OFFICE USE: <br /> - APPUCATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _______________ <br /> --- ----W ------ <br /> Date Issued <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wort, herein <br /> described-This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> I JOB ADDRESS/LOC^ATION --.----A Z_Az iX ____R-0------------------------------CENSUS TRACT _--------_--_---........ <br /> Owner's Name --------ue_t ot- -�;-------------------------------------------------------------------------------Phone ------------------------------------ <br /> Address -'-5-------R-1)------•------------------------------------------------------- City --7, <br /> 64 <br /> Contractor's Name -- � _�_:.� l' L_<' -----------------------------------------------License # r_�:_ a,,Phone ' � <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other _ ----------------------------------------- <br /> Number <br /> ________________________Number of living units:--- Number of bedrooms A......Garbage Grinder ___�____ Lot Size ____ ......... <br /> Water Supply: Public System and name _______-- _......W_A_C�','------D_.� -------------------------------_Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay E4-1�"eat❑ Sandy Loam ❑ Clay Loam El <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <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--------------_--------------------------------- Liquid Depth -----------_------------ <br /> Capacity <br /> __-__--_--_--___-_-_Capacity --------- ---------- Type -------------------- Material------------------- -- No. Compartments ...................... <br /> Distance to nearest: Well ____________________________________Foundation __-__---__--_______._. Prop. Line ___-_.__--...:._-_____ <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 /> SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ___________________________ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well --_____________________________________Foundation -______ ------------ Prop. Line ..........-........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------J <br /> / �, <br /> Septic Tank (Specify Requirements) �F� ------ /-/-)- <br /> Disposal Field (Specify Requirements) -------- RL 64T-------------------------------------------------------------------------------•----------- <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 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 which this permit is issued, I shall not employ any person in such manner <br /> as to become suble to orkman's Compensation laws of California." <br /> Signed -A-r ..... ........ <br /> Owner <br /> --- ------ ---- -------- <br /> BY ---------------------- ----------------------------------------------------- ------------------------ Title --------------- <br /> (If other than owner) <br /> FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------- ------------- DATE -------- ------------------ <br /> BUILDING PERMIT ISSUED --- --- --- ---- - --------------DATE ---------------------------------------- <br /> - --------- ---- ------ -- -- - <br /> ADDITIONALCOMMENTS ---------------------------------------------------- ---------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------- <br /> -------------------------------------------------------------------------- --------'----------------------------------- f - 0- <br /> - ----------- ---------------------------- <br /> FinalInspection by: ------------------- ---------------------------------------------------------------------- - �-------Date -- ----------------- <br /> SAN JOAQUIN LOCAL HEALTH TRICT <br /> c3 <br /> E. H. 9 1-'68 Rev. 5M <br />