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FOR OFFICE USE: ""APPLICATION FOR SANITATION PERT <br /> - ------ <br /> (Complete in Triplicate) Permit No. - <br /> ------------------------------- - <br /> r-------------------------_----------------------__-. This Permit Expires 1 Year From Date Issued 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 /> des ribed. a!_pp lllilcati miss made in compliance with County Ordinance No. 85449 and existing Rules and Regulations: <br /> JO ADDRESSAO T�/�}n'u��z; 1441 JO a" .EfS �!✓ *- f-----------.-CENSUS TRACT ---------------------- <br /> Owner's Name --��e1D1N`Tf_--- - - --- -- ------ ---- - - --------`�------- - -----Phone---zro -"--�.��-�------ <br /> �- =------ - <br /> ` Address -------------------- -- ---------- ---------- - - - <br /> `/--/-- - -- 1p' -- -- -- -- - ---Cid -` -------- c <br /> Vef <br /> Contractor's Name ..-.--_ 52. l---- ---- - ---------------------- License #�Ot _rel.__-__ Phone T_�6 I ! <br /> r Installation will serve: Residence ❑Apartment House 0 CommercialxTrailer Court I] <br /> Motel ❑Other .. ------------------------ <br /> Number of living units:------------ Number of bedrooms _-__-___._Garbage Grinder ---- ------- Lot Size __-__.______........................... <br /> k' Water Supply: Public System and name ------------- ------!... ------------------------------------------Private <br /> Character of soil to a depth of 3 feet. Sand]] Silt❑-- Clay ❑ Peat❑ Sandy Loam ❑ 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.) <br /> _ NEW INSTALLATION: (No septic tank or seepage pit permitted if ppblic sewer is available within 200 feet,) <br /> Capacity T ----------- Liquid Depth ----- --------------- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size.._.___-._____-::_'-.__ <br /> P y ---------- ---- Type ----------- ------ Material.------- - - - - No. Compartments --------------------- <br /> Distance to nearest: Wel[ ----------------------..........----Foundation ----------------------Prop. Line --------------------. \ <br /> LEACHING LINE [ ] No, of Lines ------------------------ Length of each line--- --------_. --____ Total Length --------..__-------.-_._._ q <br /> 'D' Box ------------ Type Filter Material ,__:_.__--.___Depth ;Filter Material ______.______ <br /> Distance to nearest: Well ---------------___---- Foundation ------------ Property Line - -_----._.--,.:._-. a <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter --- ------- Number ------_:---_---- ----- --- Rock Filled Yes ❑ No Cl \ <br /> Water Table Depth ------------------------------------------ .....Rock Size <br /> Distance to nearest: Well ------:_._.__.._J---------------------Foundation _________------_- Prop. Line .........---_.--__--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------___------------------- O.gte,.-------------___---------------I <br /> Septic Tank (Specify Requirements) ---------------------------------' -_-- <br /> Disposal Field (Specify Requirements) ....._ _. _ .. .-___.-_�-+ j"F. ------ -- ------- <br /> c <br /> -------------------------------A-------- - ---�-- -- ------ -------------------------- ----- ---------- - - -- - ---- ------------------------------------------ ------- <br /> ------- - - -- - - - ----------- - - ------------------------------------------------------------- <br /> (Draw existing and quired addition on reverse side) <br /> r 1 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 subject to Workman's Compensation laws of California." <br /> Signed --------------------------- ------- -- - - n Owner <br /> .. By ------- ( � . � ' Q �'/_ Title -----.-... - - -- -- - -------------------------- <br /> (If oT an owner) <br /> FOR DEPARTMENT d1SE LY <br /> ` APPLICATION ACCEPTED BY --------- - --------------------- - -- V DATE ---t-1O- -(�--�------------- <br /> BUILDING PERMIT ISSUED ----- -. ---- -------- - - - DATE - - - <br /> ADDITIONAL COMMENTS -------- --------------------------------- <br /> ----- -- ------- - - -- ---- ----------- --- -- - -------------- ---------------- ------ <br /> --- <br /> ------------------------------------------------ --------------------- -- ---- <br /> - - Final Inspection by: ---------- _----------- ----- -f - Date ------=f--- d'�l1..L�_.. ---- <br /> SAN. JOAQUIN LOC L ALTHDIS RICT <br /> c u n <br /> 1 •ao D.... cu <br />