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FOR OFFICE USE: APPLICATION 'FOR SANITATION PERMIT <br /> : Permit No. --- ---- ---------- - <br /> ----------------- -----------------•--------------------- (Compl to in Triplicate) <br /> --- ; F Date Issued <br /> ------- <br /> This Permit Expires 1 Year From Date Issue <br /> --------------------------------------------------I ri <br /> Application is hereby made to th' S n Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with��enty Ordir�apce No.5 49 anode xist`i�Rules and Regulations: <br /> %� - �� CENSUS TRACT _. _ _ <br /> JOB ADDRESS/LOC�1 -- ---70---- Cit ------------------- <br /> -Phone --------=------------------------ <br /> Owner's Name -___--r_ '! ----- ------- -^------- v <br /> r- . <br /> Address f�� �Y <br /> Contractor's Name --- �-�.-�`.,> -� ----- ----'-�=-� -- ----- ..-�....L�cense # -------�- --�-- - - -- Phone - -------------------•-•------ <br /> - _.1 <br /> Installation will serve: _ .__Residence _Apartmenfi House❑_Commerdalj]Trailer Court_l❑^� , <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units ------ Number of bedrooms -2------Garbage Grinder - ---------- Lot Size ---------•--- <br /> Water Supply: Public System and:name -------------------------- -----------------------------------'-------- ----------------------- <br /> Private <br /> Character of soil to a depth of 3 feet: Sand's Silt❑ Clay E] Peat❑, Sandy Loam -[i9 Clay Loam "❑ <br /> Hardpan ❑ Adobe-E] 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 /> I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feetJ <br /> SEPTIC TANK ] C <br /> PACKAGE TREATMENT [ ] Size_45' �G_�_k`- - ------------- Liquid Depth _-- --------•------ .- - <br /> ff r <br /> Capacity 1-U _ - ---- Type 6 `` ` - Material__�- `"� No. Compartments _r ------------- <br /> � - <br /> r Distance to neo est: Well ----__ f --/------ Foundation -------/p--------- Prop. Line ____ _-- -- <br /> ' - <br /> Length of each line-------- �'-------------- Total Length <br /> LEACHING LINE [1] No. of Lines ---.------- - g <br /> C rr <br /> . <br /> �- /­-'r'--Ty - ___Depth Filter Material ------------ - <br /> Distance to near'e tpWell"er�Md�al --- x FoundationP----------- Property Line __.__.5-------•:---- <br /> r --- - j , Number _._-- .---�.------- -- Rock Filled Yes No [i <br /> SEEPAGE PIT [}] Depth -. - -- ---- Diameter :-------- --- r - <br /> s - <br /> Water Table Depth t Rock Size <br /> --------------------------------------- ty i <br /> I a i � r. Pro Line ----" ------••••- <br /> Distance' to nearest:`Weil _______________________ _ <br /> ______________Foundation ._____. p• <br /> i <br /> ' Date ------------•-----•--------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit=# ---------------------------- <br /> ----- -------- <br /> Septic Tank lSpecify Requirements} --------------- ------= --------------------- ---------- ------- <br /> -------------------------------------- - <br /> Disposal Field (Specify Requirements) ___----------------------------------- ----------- <br /> ---------------------------------------------------- <br /> -------------=------------------------ <br /> (Draw existing and required addition on reverse si e} <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 ---------------------------------- s -------- Owner <br /> Title � U <br /> --------- ------------------------ <br /> By <br /> --------- ----- ---- -BY ---- ------------ ----------------------- -------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> j� <br /> APPLICATION ACCEPTED BY - ---� --------------------------------------------- -------------- DATE --- �- ------------- <br /> PERMIT ISSUED ------.'-------------------- --------------------------------------------------------------- <br /> =- --------- -DATE ------------------------------------------- <br /> BUILDING <br /> ADDITIONAL COMMENTS ------+----------------------------------------------------------- <br /> ------------------ <br /> - ------------------------------------------------ <br /> ----------------------- ------------------------------------------------------------------------------------------------------ <br /> -------- <br /> dl - <br /> Fina1 Inspection by. - ----- --------- --''-� ---- ----------- ------------------- -----------,--------------------- <br /> Date ._ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />