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'*FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 7 <br /> - -------------------- <br /> . = �..� <br /> (Complete in Triplicate) Permit No: <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> ---------------------- ---------------------------------- <br /> - <br /> i' <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 compliar}ce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION f-+ -------------------------------------------CENSUS TRACT ----------- <br /> Owner's Name TLRLff�----------------------------------------------------------------- ---------- --------Phone ------------------------_---- <br /> Address ------------------------------ 411------------- ----_--`-------------------------------------------- City V �-J.�S <br /> -1 <br /> RIP ------------------------------------------ <br /> Contractor's Name -------------- Q_Nib-C_tc� Au n----------------------------_----------License # 133-62.1-------- Phone ....... <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial XTrailei-Court ;❑ <br /> Motel ❑Other ---------------------- --------------------- <br /> Number of living units:____------- Number of bedrooms ___ ._.Garbage Grinder ------ Lot Size -------�A;____________________________ <br /> Water Supply: Public System and name ----------------------•----•----------------=---------------------------------------------••--•---------------Private A <br /> t -v <br /> Character of soil to a depth of 3 feet: Sand'[:] Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom <br /> Hardpan ❑ Adobe-X 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 /> P 9 i Y { <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> r� i <br /> PACKAGE TREATMENT [ ] <br /> SEPTIC <br /> PACKAGETANK:V�. <br /> Size________Ii�OO_-R91--------------------- Liquid Depth ------ ------------------- <br /> Capacity __�P6U_- -____ Type _ -_-- Material Clic- No. Compartments -------Z......_:._.. <br /> Distance to nearest: Well -----cls '______________________Foundation _---_ /_----------- Prop. Line ____ __------________.- <br /> LEACHING LINE [ ] No. of-Lines -------o__--------------- Length of each line.-_-__-/0G-------------- Total Length _c ?P_0-_--_--_______- <br /> C).4 r <br /> 'D' Box eS Type Filter Material _SC's►' 4_____Depth-Filter-Material >_------ 9___--_____________•-_-.______-. (� <br /> Distance to nearest: Well _ OPP___--____----___ Foundation ____-Z ------------ Property Line ___ ........... <br /> SEEPAGE PIT [ ] Depth __._-.-----_--- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> 1. <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------- -___Foundation ---------------.---- Prop. Line --------- ............ ,( <br /> II <br /> REPAIR/ADDITION(Prev. Sanitation Permit T# -------------------------------------------- Date ----------------------------------11 <br /> T <br /> SepticTank (Specify Requirements) ---- --- ---------------------------------------------------------------------------------------•--------------------------------------------- <br /> DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------...------------- <br /> 1 (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 became s ct Work 'sCompen afl laws of California." <br /> Signed <br /> i - - ------------------------------- Owner <br /> i ------------------ Title -------------------------------- <br /> (If other than owner)+ <br /> I FOR .DEPAfitTMENT LIS ON Y 2 <br /> APPLICATION ACCEPTED BY ------ ------------------------------------- ------- DATE 4'."- q-)/-------------------- <br /> BUILDING PERMIT ISSUED -----------I i. ------------ - -- -- - ----------DATE ------------------------------------• . <br /> ADDITIONALCOMMENTS ----------- -------------------------- ---- ----------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------•------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------- -- <br /> t <br /> -- ---------- <br /> Final Inspection by --------------- - ------------- --------------.Date --------------- <br /> SAN JOAQUIN LOCAL HEALTH TRII <br /> E. H. 9 1-'68 Rev. 5M Wr_ <br />