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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- �--------- - -------------•- -- // <br /> (Complete in Triplicate) Permit No. _.__7�' <br /> ---------------------------------------------- /—7 <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION f 6' -------�6 // 7W-----------------------------------------CENSUS TRACT -------------- ........... <br /> Owner's Name ------- J` -!-'---------------------------------------------------------------------Phone .5� <br /> Address ---------- - 5`2 C------- ---- ----------------- ------------ City --------- -- <br /> Contractor's Name ------A'_X__Z_:�/ ---------------------------------License # � �__5­4hone <br /> Installation will serve: Residence ('Apartment House❑ Commercial '❑Trailer Court ;❑ <br /> Motel ❑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: Sand'❑ Silt 0 Clay ❑ Peat❑ Sandy Loam ,CV Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type -----------------------__--- <br /> (Piot 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 se page pit permitted if public sewer is available within 200 feet,) f r <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ------- .............. V1 <br /> Capacity _.------------------ Type •------------=------- Material---------------------- No. Compartments .-----------........_. <br /> Distance to nearest: Well -_ ----------------------------------Foundation ---------------------- Prop. Line _______________ <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line --------------------------- Total Length ___________-___________._.__ G <br /> 'D' Box __---------_ Type Filter Material ____________________Depth Filter Material --------------------I----------------------- <br /> Distance <br /> ____ _ _-.___________-____..__--- <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ---------.______-_-_--_. <br /> SEEPAGE PIT { ] Depth ____________________ Diameter --------I------- Number ------ --------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ----------------------------------- --------Rock Size ----------------------------•--- <br /> Distance to nearest: Well -------------------•--------..--_:-----.Foundation -.--_--_-_--------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------y-------- ------ Date -------..-------------------------1 <br /> --------------------------------------------'----- t <br /> Septic Tank (Specify Requirements} ---- -----------•------------------------------------ <br /> Disposal Field (Specify Requirements) -, E '_C__ ----- ,C ---- _ - ------,125----1r_w ----------------------------- <br /> ----------------------------------------------------- ------------------------- ------------------------------------------------------------------------------------------------ --------------•--------- <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 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 suble�pito Workman's Compensation laws of California." <br /> Signed : - ---------------------------------------------------------- Owner <br /> By -------------------------------------------- ------------------ Title ----- --- ---- <br /> (If other than owner) <br /> FO EPARTMEN SE ONLY 1 <br /> APPLICATION ACCEPTED BY ----- ------ -- -------- <br /> ------------------------- ----------------. DATEr <br /> ---- <br /> -- ---------- - <br /> BUILDINGPERMIT ISSUED -------------------------------------------------------------- ------:------------------------------------DATE --------------------------------- -------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------------- <br /> < ------------ ------ --------- ------------------------------------------------•-•----•----------- <br /> ------------------------------------------------ <br /> Final Inspection b Date -- ---�.___-- <br /> P Y - <br /> SAN JOAQUIN LOCA HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />