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= Cf-77 - <br /> 1=0R OFFICE USE: .APPLICATION FOR SANITATION PERMIT 1 <br />................................�--• -..._..------- - � :�"�.�1-- <br /> (Complete in Triplicate) Permit No.� <br /> This Permit Expires 1 Year From Date Issued Date Issued <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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ... Y.� 3__7...... �. //' <br /> - -- -- --G��>Y�----�/D,•V .....----CENSUS TRACT ...... ................... <br /> Owner's Name s7e.17' _-Ze.IZ �/................. Pt?.,_ ............ Phone ..._......._..........-•---- <br /> Address&/ 7.__...:._..�y. ye -...� iL.Q....................... ............ City _ _... ............................................... <br /> Contractor's Name .. .....ol-"(9.i4......... ..................... .. License # ......... _...._........ Phone ...... -~_. <br /> Installation will serve: Residence QE Apartment House❑ Commercial []Trailer Court 0 <br /> Motel ❑Other .... . • ---- --•-- - ........ <br /> Number of living units:../..._.... Number of bedrooms _-_,.....Garbage Grinder .. . . Lot Size �y X� ......._. <br /> Water Supply: Public System and name ...............................................••---------•---.....----...__.............. ...................Private,E�.' <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.®r- �4 <br /> Hardpan ❑ Adobe ❑ Fill Material If yes, type ............................ <br /> IPlot 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 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK t ) Size----------------------------------- Liquid Depth -----.........._.-........ <br /> Capacity _AGO.. .. Type ..... .......... ... Material----.-. .. No. Compartments <br /> Distance to nearest. Wel) /_/..Q.-...._..._----.-Foundation ............ Prop. Line ..................... <br /> LEACHING LINE No. of Lines r <br /> [ ] �� _... ..... Length of each line.... ..�4_...__......... Total Length .,,.? .....---- <br /> 'D' Box ..... Type Filter Material --------------------Depth Filter Material .........___.......____-_.--_-___- <br /> i <br /> Distance to nearest: Well ...... _9O._ Foundation �!''���_._._....__ Property Line - - d............. <br /> ,SEEPAGE PIT [ ) Depth ........ Diameter ... Number ..... Rock Filled Yes 0 No C] <br /> Water Table Depth ...-_.:.............. _...___Rock Size ................_ <br /> Distance to nearest: Well _.._.._................................Foundation .................... Prop. Line ............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------_--_--_-.._._....) <br /> SepticTank (Specify Requirements) ---- -- -----r------•- ------. -------- -------•- -------------•-----_- ------------.......................... ............... <br /> Disposal Field (Specify Requirements) -------------------------•---------- ------- •-------------- ------...-.......-- ..........-. .--_------- ---------- ; <br /> f <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 /> "[ 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 becorn subject to Work an`s Compensation laws of California." <br /> Signed ---------------------- --------- Owner <br /> By ._. ............ ........ . ............ . . Title <br /> (if other than owner) <br /> PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... _ ......�G �._0 . ATE 1. -.--�..3--.----.--- <br /> BUILDING PERMIT ISSUED ....... ....... . .DATE . ..-..........-------------------------- <br /> ADDITIONAL <br /> __-------. -ADDITIONAL COMMENTS ---. . .......................... ---•- - -....._...---................ ...................................I..........._-..... <br /> .......................................... .. ........ .... ............... ...... ....... .-....------....-------.......----•--.-..-..---.._...---------.. ....-... ......--------•------. <br /> ------------- ---- --- -- - - -._... .._....--............ ........................ . . <br /> Final Inspection b Date ._-.,� . <br /> .. ...... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E H 13 241_'68 Rev. 5M 7/72 3 M <br />