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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -- ------ -- --------------•--- --------------- <br /> Permit No: <br /> {Complete in Triplicate} <br /> ---------------------------------- 7 3 <br /> / Date Issued ....3 ------ <br /> This Permit Expires 1 Year From 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 /> n <br /> JOB ADDRESS/LOCATION ..... I�'�5---- 5----- J'; ------ <br /> -----------------------CENSUS TRACT -------- - - ------- <br /> Owner's Nam(ye�-. -------------------- ---------------- ---- Phone -------------------------------,----- <br /> AddressJ7� E 1I� iZ_ City ,F� G p� <br /> Contractor's•Narrie_. ---•• <22n�'� �--'�-------------------------------License #�-����.� PhoneO-� " <br /> Installation will serve: Residence ® Apartment House,❑ Commercial []Trailer Court l❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-... ------ Number of bedrooms __3----- Grinder ------------ Lot Size --------_----- <br /> Water Supply: Public System and name -----------------------------------------------------------------•--------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand I Silt❑ Clay ❑ Peat ❑ Sandy Loam [I Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ------------------_.____.-- }� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,;.etc, must be placed on reverse side.) 00 <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if public- sewer.is available within 200 feet,) _./ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size - - _.lC_X.. .__---- Liquid Depth _L_/�-.-__----- 00 <br /> Ca acit /�Pa------ T e ___..Ste___ Material_ No. Compartments 2J <br /> P Y - -- YP - ---- - <br /> ----.----- <br /> istance to nearest: Well .. --......__-_.._.._..--.-Foundation .1'9-r--..___... Prop. Line _.�}................ <br /> r <br /> LEACHING LINE No. of Lines _.__ ------------- Length of each line-----1P r---------- Total Length - -------- <br /> 'D' Box ------------ Type Filter Material _Pate �r----Depth Filter Material ---------------------------------- <br /> Distance to nearest: Well ------s'' ___7----- Foundation -------/.-L1-----._.. Property Line --------------- ----- -- <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ------------------------------ Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest. Well ----------------------------------------Foundation -`----------'.------- Prop. Line ------------.-........ �t1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ----------------------------- <br /> -------------- - -------- Date --------------------------`--------) <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------------ ------------------------------------- --------------------------.. 1 <br /> Disposal Field (Specify--3equirements) -------------------------------------------------------------- I---------1-------------------------------------------------------------------------------- <br /> ~ <br /> i ------------------------------------------------------ - <br /> --- ------------ - <br /> �, i~t -r --: - <br /> -------------------- -----------------------i----------------------------------------------- ------------------------------------------------- ------------------------------------------------------ <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 shalt not employ any person in such manner <br /> as to become subject to Wo! man's Compensation laws of California." <br /> Signed ------- ---- ----- ----- -- ---------------------- --'-- - -------------------------------- <br /> Owner <br /> (ZABY ------ ---- — — - ---- Title <br /> (If other th n owner} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- n .P,--- ---------------------------------------------------------. DATE .-.-1`-. ��.. ---------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------- ----------------------------- --------DATE ------- ------------------------------ <br /> ADDITIONAL COMMENTS -- ------------------ ------------------------------------ ------=----------- ---•----------- <br /> ----------------------------------------------------------------------------------- <br /> ---------------- -------------------- ---------- ---------------------- ---- ---------- --- - ------------------------------------------------------------------------- <br /> ---- - ------ ------------------------------------------------------ ------ <br /> Final Ins ectE = _ ------ - -- ---w--- -�. ate ------- -----------------?%-t------- <br /> SAN JOAQViW"LOCAL'HEALTH DISTRICT— <br /> E, H. 9 1-'6$ Rev. 5M <br />