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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....................... -------- No. <br /> - ----------•- (Complete in Triplicates Permit ..................•-. <br /> .............................................. . <br /> ......................................................... This Perrrdt Expires II Year From Date issued <br /> x-3'. <br /> Date Issued ._S; 7 6 <br /> Application is hereby mode to the'San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is mode in compliance with County Ordinance No. 5,49 and exi ting Rules and Regulations- <br /> JOB <br /> 1- <br /> ,,�r ) /T - J <br /> JOB ADDRESS/LOCATION ...... . __�P.�/�C .J..._....I/-... [71!T QtL E... !..............CENSUS TRACT ..................... <br /> Owner's Name ... . . - ----•- -- ............. .....................Phone ........................-.--..------ <br /> Address . ......._..4.1 / ----------••--.........---.. CI ----------------------------------•-------- <br /> Contractor's Name ............License4 ...................... Phone <br /> y_ f <br /> Installation will serve: Residence[�partmennt•House fl Commercial railer Court-0------�-�-� <br /> Mote! j]Other,..'........._-� <br /> E <br /> Number of living units------------- Number of bedrooms ......Garbage Grinder .........•.. Lot Size ....................:....................... <br /> i <br /> Water Supply: Public System and name ...... -------- ---`----- ��"..... :........ .............Private 0 �A <br /> Character _- <br /> of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ r Sandy Loam 0 Clay Loam <br /> u <br /> i Hardpan Q Adobe 0 Flil Material ............ If:yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of systemin` r lotion to wells,-.buildings, etc, must be placed an reverse slde.) Q <br /> \ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted'lf public sewer is�avallable within 200 feet,) <br /> s <br />' A KAGE TREATMENT size <br /> I . .-•. *. <br /> Liquid Depth <br /> Capacity tyType ....._ _._ - Material...................... <br /> NF—Compartments <br /> Distance. to nearest: Well ......................... .........Foundaflon�.................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line..................... ...... Total Length ............................ <br /> 'D' Box ---I-------- Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearest: Wel! ..............:........ Foundation ..............`...._... Property Line ................... <br /> SEEPAGE PIT Depth ..... ...___-_.-_-- Diameter .........--- Number -----''�"......... ......... Rock Filled Yes Q No C1 <br /> Water Table Depth .................................................Rock Size ------------------• ............ <br /> Distance to nearest: Well ----------------------------------------Foundation __ ................. Prop. line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date <br /> ............................ <br /> SepticTank (Specify Requirements) ............ ...... -----------......-----.....----............�..,__. .......w................. ....................................... <br /> Disposal Field (Sp ify Requirements) _______________ __ -------------------------- <br /> ------------------------------ <br /> ... ..................- <br /> -----•-------- <br /> yam. /+� <br /> - 4 �-0?a.• 4r� � -L�tes�= ----6 rs3 .... F�.:� ...................... <br /> --------- ---- -- ---- -- • • ----------•-- ---- <br /> (Draw existing and required addition on reverse side) r <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. Nome 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." " <br /> Signed ------ • - -------------------------------------- --------•----•--------.......------•--------- Owner <br /> By ------------------------ -- -------------------------------------------------- ......... xitle ---....----- -• -- <br /> (if other than wnerl <br /> OR"DEPARTMI:I Y-USV_—dNLY <br /> APPLICATION ACCEPTED BY ---------- �°- --------- DATE ._.. :3.". ------------- <br /> BUILDINGPERMIT ISSUED -------------------- ----------- ......--------------........-----------------•-----.------------..DATE .... . ----.....----...................... <br /> ADDITIONALCOMMENTS ---......-- #-----------------------------•-----------•-•-• - .......... .-----------------•......._.........--------=.................... ...... <br /> l ...-- -------------------- -------------------------------­ ------------...------....----------- ..... <br /> .-..-............_ .....----..... <br /> ----------------------------• ------------------------ ----------------------- . -•---------------------...-----------.-----.....------........----.......... ----------------------•------ ....... ..... ............................ <br /> ............Date ..... ... ................ <br /> final Inspection by- ----------------•--- ........ . �--- --- -�±..-•---••------.....-.--.--.---....------..._. _ / 2e _ <br /> EH 13 2L 1-68 Rev. 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8-A 3M <br />