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FOR OFFICE USES <br /> '- — APPLICATION FOR SANITATION PERMIT <br /> ---- --------------------------------------------JPermit <br /> (Complete in Triplicate) �--------------�-- <br /> - This Permit Expires 1 Year From Date Issued Date Issued <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 dpplication is made in compliance with County Ordinance No. 549 and existin Rules and Regulations: <br /> LA-`H Fav_ <br /> JOB ADDRESS/LOCATION .___2z_7�-----F------11 -- _--------1ZC-_______-__-�------------CENSUS TRACT --_-_ "- (------ <br /> Owner's Name ---------R--------�QVPj��-------- ��lr i --------------Phone �gs_ 2173!2 <br /> 1 5� C <br /> Address / -F---- ----- j 1 O-------------. City --- _�_-..o�.------------------------------------------ <br /> Contractor's Name -------C10,-4V-!-te --------------------------- -------------------------- License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House-E] Commercial :[F eer Court i❑ <br /> Motel E3 Other -------------------------------------------- <br /> Number of living units------------- Number of bedrooms ___________Garbage Grinder ------------ Lot Size _____________________._________________ <br /> Water Supply: Public System and name _______________ __-______-_-_____--Private ❑ <br /> Character of soil to a depth of 3 feet: SandfEr Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________________ N <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,) Q V <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size-------------------- ------- -------.----------_ Liquid Depth ------------- -__-- <br /> Capacity 14;�--__-- Typb��/�P _/_____ Material-c/ _ � No. Compartments ___-Z%!------------ <br /> Distance to nearest: Well _---_c �______________________Foundation ____ __._________ Prop. Line �t________f+?1�.V <br /> LEACHING LINE [,rNo, of Lines __ ------------------ Length of each l ine_____C'l_d�_____..______ Tota! Length .......... <br /> N <br /> 'D' Box .__ Type Filter Materia ,ee-_4 _Depth Filter Materia! ------AJ______._______ ______________ <br /> Distance to nearest: Well __s.}_=L?_ - +� <br /> ____________ Foundation ---AO Property Line ____ (.hr...._ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- e\ <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ____._____..____.___.. a <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------- -------------------------------------------------------------------------:--------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 folio ' <br /> "I certify t e erfor of the work f which this p rmit is issued, I shall not employ any person in such manner <br /> as t ome sub' to Workma `Co pen o ws C ifornia." <br /> Signed - ------ - - -------- ----- - - - - --------- ------------- Owner <br /> By ----------------- ----------------------------------------------------------- ------------------------ Title ------------------------------ ---- ------------------ ---- ------------ <br /> (If <br /> ----------------- <br /> - --------------------------------------------------- <br /> (If other than owner) <br /> FOR QEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----__ ---------------------------- DATE .... -'�-----_------- <br /> BUILDING PERMIT ISSUED ------------------------ ------.--------------DATE ---------_---.---------__ <br /> ------------------ <br /> ADDITIONAL COMMENTS - ---------------------------------------------------- ----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------- .. <br /> - -------------------=-- - --- <br /> ------------------------------------------------ - ---- - ------ - <br /> Final Inspection by- -------------- -- _ _ Dat-e- - ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �!H. 9 1-'68 Rev. 5M <br />