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s <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- --- -------------------------- ------- <br /> (Complete•in Triplicate) Permit No: <br /> ---------=----------------------------------------------- <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 compliance with County Ordinance No. 549 and existing Rules and,.RegOlations: <br /> JOB ADDRESS/LOCATION _ &gjrAl----!_Z.- if- - ------4?->----- . --- ----------------CENSUS TRACT.'., �-5 ------ <br /> i , � .C,/�,•�i_ a i , J C>N ------------- - Phone.. 9'"J � • <br /> Owner's Name l.-/ /Y� j <br /> Address __I glryo----... \1_FK-------RD---------�= City -- )FO— i-- i r I <br /> ----- i <br /> F <br /> Contractor's Name _QW_10 �-------------- -------.License # ----- ------------------ Phone------------------------------ <br /> Installation <br /> ------------------------Installation will serve: " `Residence)'Apartment•House-[] Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- �,� <br /> Number of living units:..__-�_-.. Number of bedrooms __Garbage Grinder rVd F- Lot Size _ R , _�.r :---.--__. <br /> Water Supply: Public System and name ------------------------------------ ��--------------------- -----------Private <br /> Character of soil to a depth of 3 feet- ! Sand'[:] Silt❑ Clay E] Peat E] San d,y Loam, ,Clay Loam ❑ <br /> Han <br /> rdpan F1Adobe '❑ Fill Material -A -- If=yes, type-------"-�--------------- <br /> (Plot plan, showing size of lot,-_jlocat1on,of .. stem in relation to wells, buildings, etc, must be placed on reverse side.) <br /> 11 1%0 <br /> NEW INSTALLATION: (No septic tank or seepag it permitted if public sewer is available within 200 feet,) •� <br /> PACKAGE TREATMENT [ } SEPTIC TANK'[ ] Size_______________________________________ quid Depth --------------------------- <br /> �f , <br /> I Capacity ---- ----------- TYp -------------------- Material----------------- No. Compartments <br /> t Distance to nearest: Well ------------------------------------Foundation '---------- --------- Prop. Line ---------------­----- <br /> LEACHING LINE [ ] No. of Lines _-------------------- - Length of each line--------------------.___ otal Length ______-_____________....-_ <br /> 'D' Box ----------- Type FilterMaterial --------------------Depth Filter Mate,i-al -------------------------------------------- , <br /> Distance to nearest: Well __ _____________________ Foundation ______.____-:-_------ Property Line. ___--__________-.....-- <br /> SEEPAGE PIT [ ] Depth----:-:^:-- -'-'-Dia ------ Number ------------------ -------- - Rock Filled Yes ❑ No 0 <br /> Water Table "D.eptFi -------Rock_Size,=,-j------= <br /> ----------------- <br /> Distance <br /> --------------- <br /> Distance to nearest: Well --- ---------------------------- •' Foundation -' --- -:,._-' ._ Prop. Line ----------- ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit Y# --------------------------- •---- -- Date ------------- <br /> r - ----------------- <br /> Q _Septic Tank (Specify Requirements).--, /_Sn ) <br /> -- -------- ----- /_,b 4�------ <br /> Disposal Field (Specify Requirements) .10/V�-------)qt>, r::-----.50---=•'- xIS7 <br /> g and > ---------------- - <br /> ------ ---------------------------------- ---------------- <br /> Dw eraxistin re aired addition on reverse side) t <br /> r II 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 ofthe San Joaquin LocalHealtFi, District. Home owner or licen- <br /> sed agents signature certifies.the-followinge _ r _--. �:-- <br /> "I certif t in the perfor ce f the work for which this permit is ssued, 1 shall not employ'any person in such manner <br /> as to bec a subject tork 's Compensation lawtiof California." <br /> Sign - -- ----- -- ---------------- Owner <br /> --- <br /> c <br /> By ---------------- --------------------- <br /> ------------------ <br /> --------------•--------- ----------------- - - --t---- --�---- Title ---------------------------------, <br /> (If other than owner) F <br /> FOR DEPARTMENT USE ONLY <br /> -} 1-------- <br /> APPLICATION ACCEPTED BY ---------- -1'R=C� - - DATE = <br /> BUILDINGPERMIT ISSUED -------- '----------------------------------------------•----------------------- ---------------DATE - --- ------------------------------------- <br /> ---------------- <br /> ADDITIONAL COMMENTS . =-- - - --------------- --------------,----------------------;----- ---------------------------- ------------- <br /> ------------------------------------------------------------------ <br /> ' ---------------------- ------------------------------•- <br /> ---------------------------------------- ---- <br /> --------- - --- --------- -- '----- -- r - - --- <br /> -----------k- ---------------------- <br /> ------------- <br /> Final lnspectio_r by, - _ <br /> - - - -- -----------`-----------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'GS Rev. 5M <br />