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PPV <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------- .., <br /> (Complete in Triplicate) <br /> x_l <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> --------------- - -/l! ------- --------- <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 .-------------2 -------7---S---------S--1-----� �- k/leea__-_-------CENSUS TRACT ------------- <br /> ----------- <br /> Owner's Name s U�i'r - f_C -R-1--�------------------------------- -------------------PhoneS--------- <br /> Address ---------------------------------------Jl-�-`3k!xc e------------------------------------------------------------------------------------------ City ---------------------------------------------------------------------------- <br /> Contractor's Name ------------ ----- ----------- ---------------------------------- -------.License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House,❑ Commercial ❑Trailer Court ❑ <br /> Motel [Other .__Odt* ___g rh T'1r f <br /> Number of living units:)//_f__ Number of bedrooms ------------Garbage Grinder ___________ Lot Size __________________-______________-__- <br /> Water Supply: Public System and name --------------------------------•------- --------------------------- PrivateK <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 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 3 pubblic sewer is available within 200 feet,)o 41, ` O <br /> PACKAGE TREATMENT [ ] SEPTIC TANK (A] Size---------------- __.________ ___._------------- Liquid Depth <br /> _____'�_________ <br /> ______ <br /> Capacity ___ -_----- Type -------------------- Material__Cq x ��- rNo. Compartments ------�........... <br /> `�� ®Distance to nearest: Well --------- <br /> ______'_� UFoundation _ ______-_ Prop. Line �_ :__ <br /> LEACHING <br /> LINE K No. of Lines ----------/------------ Length of each line---------gQ ff___ Total Length ------- 'Q_ f...... <br /> D' Box __ q___ Type Filter Materia f___1_t__ ° epth Filter Material _____-_ <br /> �,-----------•----------- <br /> Distance ton rest: Well __>_SB_ _____ Foundation - �Q_ Property Lined© ___..__._.-. <br /> SEEPAGE PIT [ ) Depth ---Y1'-'-____ Diameter ________________ Number ._______________ ----------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ----------------------------------------------_Rock Size .------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------ �-____-__.__._ Date __________________________________) <br /> SepticTank (Specify Requirements) ------------------ -------------------------------------------------------------- ------------------------------------------------ -------- <br /> Disposal Field (Specify Requirements) -__-_______ ___________________________________ <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 :toerformance of the work for which thi permit is issued, 1 shall not employ any person in such manner <br /> as to become subject e a if n'a." <br /> ��nnSigned -------X------------- ------� (�--------- Owner <br /> BY ------------ ----------------------------------------------------------------------------- Title .----------- <br /> ----------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- - -------- ---I--- <br /> - - <br /> - ---------- --------------------------- - -------------. DATE ------ ----------------- <br /> - <br /> BUILDING PERMIT ISSUED --------------------------------- ------ -------------------- ------- ---------------- --------------DATE ------------- ----------------- ----------- <br /> ADDITIONALCOMMENTS --------- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------•------------------------------------------------------------ ----------------------------------------------------------------------=-------------- ----. <br /> ------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- ------- <br /> -------------------------------------------------- <br /> -- ----- - - --- -- ---------------------------------------------------------------------------------------- <br /> --- -- <br /> ------ <br /> Final Inspection by -¢~-----------------------------------------------------------Date ------1—/i <br /> -- ----------------------- <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />