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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....................... --....... Permit No. .7VJ. ...� <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued .....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 Regulations: <br /> JOB ADDRESS/LOCATION .............�� _ <br /> ..�..��-�r-..-..�-•-5���/ .............:..:.CENSUS TRACT .................. <br /> Owner's Name ....... cTf��./ii....... films _._....--- ..................•-- ----------.... ............ Phone `�,w...5.;_ ��� ...... <br /> r -.._... <br /> Address ............: //.aJ`......JI i.�a�c ......._._:. r � .R City �� ' /d� <br /> Contractor's Name .........4-7-e.t_: —r sem`—�fl :Phone—" c�;.�e'�/ <br /> ( <br /> Installation will serve: Residence IqApartment House,❑ Commercial []Trailer Court ❑ <br /> Motel ❑ Other ...... ... ----------------------_---- <br /> Number <br /> ... ------------_---Number of living units-.../- Number of bedrooms .�-----Garbage Grinder ............ Lot Size .. .:............. ... ........ Qy <br /> Water Supply: Public Systemandname ...................... _------Private ® `r'► <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam V Clay Loam ❑ <br /> �l Hardpan ❑ Adobe ❑ Fill Material ........ If yes, type ........... ................. t <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 feetlj <br /> PACKAGE TREATMENT ( ] SEPTIC TANK[ ] /�] Size---li._X.�S__ y................... ...... Liquid Depth <br /> ............... <br /> Capacity /. .U7J. Type 1 W6'75 - C Material............. �- ' ..._.... <br /> ..._._.._ No. Compartments ._.._. ...... <br /> Distance to nearest: Well .............................Foundation .vZo.._�........ Prop. Line ... �........_ <br /> x <br /> R .. 1✓ � f <br /> LEACHING LINE [ ] No. 'of Lines IP,__ Length of each line_..- . p-. .....#...._. Total Length Q.._-_- ---- <br /> 'D' .Bax .__� Type Filter Material _� _xDepth Filter Material ................ <br /> I !: .. ..................... E <br /> Distance to nearest: Well � _�__ Foundation -�f. ............. Property Line <br /> SEEPAGE PIT [ ) Depth ........ Diameter ._..._....._.._. Number ............ ............ Rock Filled Yes ❑ No [] <br /> Water Table Depth -- -------....................................Rock Size '':... ------­---------- <br /> k • <br /> Distance to nearest: Well ........................................Foundation ..-I .......,...... Prop. Line ...................... f <br /> t <br /> REPAIR/ADDIT€ON(Prev. Sanitation Permit# --------. --------------------- - •-.-•_._-- date _. �_;t' a �........._.......) <br /> Septic Tank (Specify Requirements) .......... ......... .. ------....------------.....-..---••--------- ............j .. <br /> €' ) <br /> Disposal Field (Specify Requirements) ........................... .......i................I............... <br /> �- - ."---------- ----------- ....•----•--------------------------------------- -----......---• .... �._..-.. <br /> ........... ....'...........----••------....----- <br /> ! f. .r. <br /> (Draw existing and required addition on reverse,sidej <br /> hereby certify that I have prepared..this application and that the wort "W' it be done in accordance with San Joaquin <br /> County Ordinances,,State Laws, and Rules and---Regulations of the San Joaquin Loca Heolth District. Home owner or licen- <br /> sed agents signature certif€es the*following: _ ' <br /> "I certify that lin'the performance of the work for which this permit is issued-,-I-shall_not employ any person in such manner <br /> as to become subiect t Wor an's ompensation laws of California: <br /> " t t <br /> Signed -� - -��-� - -•---�--- -- - •------ - --------------------------------­ •- ---- Owner t <br /> By ....... ..... ----.... .......... -- _. T•,Title......-. .... .. ........ ............... . ... ........... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - .� �__. —y.. DATE h.....�`"..-. ..._...'"" ..--.- <br /> BUILDING PERMIT ISSUED . •--- .-• •. . ..............DATE .....---....----- ...................... l <br /> ADDITIONAL COMMENTS . --------.-• -- ----- . -- :. .....:................... t <br /> ........... ----------- ...------......----...----- -------------•-------- -- • ................................ --- ----- .-......._._......_: <br /> ------------------------------------ <br /> ------------.-------...............----- ----- ----------- <br /> . . <br /> ','Final Inspection by: -.._. ----•----- ---------------------Date .... <br /> _.._... " .._.... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />