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FOR OFFICE' USE: - APPLICATION FOR SANITA`IONI'PERMIT <br /> ----- - ----- ------ --------- -------- Permit No. <br /> (Complete in Triplicate) <br /> ,. 4 - <br /> ------------ <br /> This Permit Expires 1 Year From Date Issued Date Issued ___��_ ✓�� <br /> r Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> tr1`11 <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regyltions: <br /> -- I <br /> JOB ADDRESSACIC�A,T/ION ._/ _____ _ ��- R�� - <br /> tl� !�-�10���/1✓_._ /q_ /�'/f9 ----------------------------- -------CENPhone RACT <br /> Owner's Name _ =--------�------ <br /> Address ---- .....0 51 � 0 PA,a-----------------------------1--. City ---------------------------------------------- <br /> __.Licer <br /> Contractor's Name ---7�X���---------------------------------------------- se # <br /> -------------- Phone ---------- -- ---- <br /> Installation will serve: Residence A-)(partment House,❑ Commercial❑Trailer Court ,❑ <br /> Motel ❑ Other ----------------------------------------' <br /> Number of living units:________ Number of bedrooms _:____Garbage Grinder ol/ _ Lot Size /C!9- <br /> Water Supply: Public System and name --------------------------------------------------------------1------------ - ---------------- ---------------Private <br /> j <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ . Peat❑l� Sandy Loam ❑ Clay Loam.;( <br /> 1141, A�. <br /> Hardpan ❑ Adobe'❑ Fill Material __t IV--- If yes,type --------------------- <br /> (plot <br /> ------- -----(Plot plan, showing size of"lot, location of system in relation to°wells,,buildin s, etc. must be placed on reverse side.) <br /> � <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is aavfailable within 200 feet,) <br /> PACKAGE TREATMENTSize-3/SEPTIC TANK __.�_� <br /> ( l � . --- ��-- - ---------e Liquid Depth I-------------------------- <br /> Capacity p _..; Typ es. . --_ Materiaaw t,04� Nor Compartments ' ............... <br /> - _ v <br /> # i <br /> Distance to nearest, Well ��•�_______ ____._._�..__ _Foundation�P ' ______..___ Prop. Line ------ <br /> LEACHING LINE [ No. of Lines - __ _____________ Length of each line - - -______"Total Length __..___._.._.__ <br /> D' Box __ _ <br /> _ l�C` Depth 'Filter` Material /--��--------------�­----­----- <br /> Distance <br /> --- ----- <br /> Distance to nearest: Weller(>�at©n�I+7tFoundation' _`he _T- Property Line_ __.--___ <br /> SEEPAGE PIT [ ] Depth _____ _..__-___- Diameter». : _ ----Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ----- -------------------------------- _.ltockr3.- � ----- 1-------- -------- <br /> t I . <br /> Distance to nearest: Well r oun tion Prop. -- <br /> ...... .......... <br /> t <br /> REPAIR/ADDITIOl+1(Prev. Sanitation Permit# •------- -- -- J° <br /> $ - - -� tel -------�--- ---) <br /> Septic Tank (Specify Requirements) .._. --------- --- --------------------------- <br /> Disposal. Field (Specify Requirements) ------------ ---- -- - - ---------- <br /> ---------------------------- <br /> - -----._ __ _-_ --------------- ------------ ___ _ _ 1___ _ _____ ------------.------------------------ <br /> ------------- <br /> ______ ____ ______ _ __--- - --- ----------- --------t--- -_--..---i - -------- - ---- - -- - ---- <br /> (Draw eiisting and required addition on,rivet se 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 Mules and Regulations sof 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,,l shall not employ any person in such manner <br /> • 8 <br /> as to become subject to Workman's Compensation laws of California." <br /> i <br /> SigneOwner <br /> By ---0--f''vJ< b - ---------------------- ----------- ----------- Title x ' � <br /> (If other than own <br /> FOR DEPARTMENT USE ONLY, <br /> y APPLICATION^YICCEPTED BY `_� 1}3 0` ___-- DATE <br /> -- - --- <br /> BUILDIi*JG.tiPtR'MIT ISSUED ---- ----- --------- --- ------ -- -- --------DATE ---- <br /> ADDITIONiCOMMENTS --------------------------------------------------------------- --------------= --------------------------------- <br /> ----------------------------------- ------------------------- ------------------------'''------------- <br /> -------------------------- ------------------------------------------------------------ <br /> ---------------------- - =------------- --------- ------------------------------------------ ) -----------I------------ <br /> ------ <br /> ---------------7----------------------------------------- ---------------------------------- ------- <br /> Final Inspection by: - ------------ ---- ---- -- ---- ------ - ---- ----- ----------I------- Date --------------------------------------------- <br /> SAN <br /> --------- ------ -- - ---- <br /> SAN JQ-AQUIrzT LOCAL HEALTH DISTRICT <br />, i,<,n E. H. 9 1-'68 Rev. 5M <br />