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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - (Complete in Triplicate) Permit No. _____________________ <br /> � <br /> � ------------------------- This Permit Expires 1 Year From Date Issued Date Issued __6-711-13 <br /> ------------------ <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 ,/ / z�..r--/-- -•__> r"' �-----------------CENSUS TRACT -' 7 <br /> ----------------- <br /> Owner's Name !? _ /` = ---------Phone .----------------------------------- <br /> -........ ' l�c� ---------------------------------------------------------- = = City � ` <br /> Contractor's Name -----,/ i '1�-- X 11---------------------------------License # i __ PhonejW�". 1 . <br /> Installation will serve: Residence$Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other --------------------------------------------- <br /> Number <br /> ------- --------------Number of living units:--/___--_ Number of bedrooms .,..Garbage Grinder k�1;__ Lot Size ___________________ <br /> Water Supply: Public System and name --------------------------------------------------------------- ----------------------Private <br /> Character of soil to a depth of 3 feet: Sand T:] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ I 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 /> b� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if publicsewer is available within 200 feet,) 1 V <br /> PACKAGE TREATMENT [ SEPTIC TANK!V Size__- __,` 9s �____________________ Liquid Depth _01`'z,------------------ V\ <br /> Capacity I, _____ Type�,,'Vr -- Mpterial_d,&_/f&__-___ No. Compartments ---ZTrn�----------- ( <br /> Distance to nearest: Well _-____- ...........Foundation _ f _ e--------- Prop. Line _Z47 <br /> ��_.__ ` <br /> LEACHING LINE No. of Lines ___ -________-_____ Length of each line__X __ ------- <br /> Total Length ,��_�__.__________- k` <br /> 'D' Box 1e..;_._ Type Filter MatericiAtexeeeDepth Filter Material _~_________________________________ <br /> Distance to nearest: Well _,� 1-1----__ Foundation __X�-�__--_--- Property Line --I��______ _ <br /> SEEPAGE PIT X Depth _�,r_�---- Diameter _ �_ Number ---- ____. ------ Rock Filled Yeses No Ci <br /> Water Table Depth -------l0110, <br /> �-------.---`-----------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 /> ------------------------------------------------------- -- ------------------------------------------------w----------- -------------------------------------------------------------------------------- <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 subject to Workman's Compensation laws of California." <br /> Signed ------------- Owner <br /> -------------------------------- <br /> --- Title - -----t <br /> they.than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------•---------- - DATE -�-----, _�------------------ <br /> BUILDING PERMIT ISSUED ------ -------------------------------------------------------------------------------------•-------- ---DATE .---------------------------------------- .� <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------=------------ -•----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------"-"--" ------ ---------5- <br /> -------- - - - ------- - <br /> Final Inspection by: ---- - w ec°� -----------------------------------------------------------------------hate ---;7 --------- - <br /> 3 - L _ ---------- <br /> M <br /> SAN JOAQUIN LOCA'r: HEALTH DISTRICT -----_ti <br /> ' E. H. 9 1-'G8 Rev. 5M <br />