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FOR OFFICE USE: j <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- ----------------- ------------------- <br /> (Complete in Triplicate} Permit No:"- -Z _ -------- <br /> Date Issued <br /> ` ---_- ` 'This Permit Expires1 Year From Date Issued---------------- <br /> t <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 ig'Sompliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> '�a <br /> z �JOBrADDRi S5/LOCATION ._. �E -------- -----------' ----- - " - CENSUS TRACT <br /> ChSiner's Name l._l- ---- - Phone <br /> Address ------------------ <br /> -AV <br /> 1 City <br /> �u <br /> Contractor's Name '--------l-- - ----.License # . `C1's Phone. <br /> Installation will serve: Residence -Apartment House❑ Commercial ;❑Trailer Court .0 <br /> ; otel ❑ Other -------------------------------------------- <br /> Number <br /> ________________Number of living units:---- Number of bedrooms _- _...Garbage Grinder ________*__ Lot.Size _.------------------------------------------ <br /> Water <br /> -________ _____________________________Water Supply: P6blic5ystem and�name ---------------------------- <br /> r ----------------------Private Q" <br /> Character of soil to a depth of 3 fleet: . Sand:EJ Silt 0 Clay ❑ Peat❑ Sandy l Loam 2, Clay Loam <br /> 0 <br /> Hardpan E] Adobe.0 Fill Material ____.___-__ If yes,type _______________________ <br /> (Plot plan, showing size of lot„ location of system in relation to wells, buildings, etc. mut 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 T,ANK'f ] Size------------------------------------'---- ----Liquid Depth ---------------------._--- 14N <br /> Ca acit r ----- Type -------------------- Material-------- --------' -- <br /> -- No. Compartments ------ ---------- <br /> t p Y -; i-I----e <br /> #3 Distance to ryLirest: Well ____________________________________Foundation __._.__`______._______ Prop. Line _--___________ 161 <br /> _....___ <br /> [e� ��-------- -- Length of each line___- - -- Total Length <br /> _____/+__f9___0�---.-.-- <br /> D' Box <br /> LEACHING LINE No. of Lines .� ---. _i_ <br /> �. ate' Depth Filter Material <br /> - -tiType Filter Material ----------------- - -------------=--------------•-•------------- <br /> 1 Distance+to nearest:',Well -----''ri'"_---------- Foundation ___jl_!�_i---____ Property Line ---- <br /> --_: ____SEEPAGE PIT [ ] Depth ------ __- Diameter ----------__---- Number --------- ------------------- Rock Filled Yes �❑ No 0 <br /> Water Table D th - ------------------------- �-----------Rock Size --- --------------------------- 6 %J°" p <br /> tj <br /> REPAIR/ADDITION(Prev. Sanitation Permit� -'ell ________________________________________Foundation -_.____.______._.-__ Prop.(,Line ...................... Q <br /> Distance to nearest: W <br /> ------------------------------"'-------- Date --'- ---------- <br /> ____-_______ '-_" 4 } f <br /> .�I � � � J� l <br /> Septic Tank (Specify Requirements) ' O ------- - <br /> -----' ------------------------ <br /> Disposal Field3(Specify Requirements) -�---------- -:---------------------------- -- -- -- {----------------------------- - --- - <br /> ------------------ --------- ------ <br /> ---- ----- <br /> - ------------------------ <br /> ( Y ��pF <br /> _____________ -----------------------_---------------------------------SR _. /_____ ___-________________.___________-_---__.------------_______-----------------------------------------___---------- <br /> "."" :.:.(D�w-6ist'n'.g and required addition on reverse side) 1 <br /> I hereby certify"that I haMre 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 /> BY - -Q..(If�other than own : 1 E---k;JL4 .Ti#le <br /> e'' ° <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- - --------------------------------------------------------- DATE ----------------------- ---------•--------- <br /> BUILDING PERMIT ISSUED ---------=---------------------------------------------------------------------------------=--------------DE -------------------------------•----------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------------- - ---------------------- -- - <br /> --------------------------------------------------------------F <br /> ---------------------------------------------------------------------------------- ------------:------------------------- <br /> - �� --- <br /> - <br /> � firrFinal Inspection b ----------------------- -----------------------------------Date -------------------------------------------- <br /> SAN <br /> --- -- - _ --- -_ -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5Mz 'y_ <br />