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FOIA OFFICE USE: APPLICATION FOR, SANITATION PERMIT <br /> Y, Permit No. __. 7-=--------� <br /> ' (Complete in Triplicate) <br /> This Permit Expires 1 Year From bate Issued Date Issued <br /> ---- ----- _-- --------------------_----_--------- <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 .-. CENSUS TRACT <br /> Owner's Name - - Phone --------------------• -------------- <br /> r C� <br /> Address ------ ---e a -- City ` <br /> Contractor's Name s6� ------ ------.License # ----- ------ ---------- Phone ------------------- ---------- <br /> Installation will serve: Residence ❑ Apartment Hou e❑ Commercial ❑Trailer Court C]Motel I❑.EW6r -----l ------------------- <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 fl Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 <br /> Hardpan ❑ Adobe'❑ Fill Material ;----------- If yes, type ___------------------------ <br /> (Plot plan, showing 'size of loft, 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[ ] Size---------_--•---------------------------------- Liquid Depth ----------------i.- ---; , <br /> Capacity -------------------- Type -------------- -=-- Material---------------------- No. Compartments ------ <br /> __Foundation _____________ ____ Prop. Line ____-..--____.•- I <br /> Distance to nearest: Well. _________-_-------------------- -------- <br /> Distance <br /> jc- (1 <br /> LEACHING LINE [ ] No. of Lines ------------------------xtength:of"each line---------------------- Total Length ----------•----------------• <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------•---- •---•---•. m <br /> i <br /> Distance to nearest: Well ___________________- _ Foundation ------------------------ Property Line ------------------------ <br /> SEEPAGE <br /> ____.-._______--_. --SEEPAGE PIT [ ] Depth ____________________ Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No .❑ <br /> iWater Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ------ Prop. Line --------------..------ �+ <br /> REPAIR./ADDITION(Prov. Sanitation Permit# --- ------ --------------------- Date ____-_-__-_---------------------- 1 <br /> Septic Tank (Specify Requirements) -- -_---- ` `"` /��Q ----------------------- <br /> Disposal <br /> ----------•---- :--- <br /> ---- --- - - <br /> C <br /> Disposal Field (Specify Requirements) __ __ __________ _______ _ ------- <br /> -------- <br /> --------� <br /> -------------------------------- <br /> ------------------------------------------------------------------------------------------- -----------------------------------------•------------------_----- <br /> r. ----------------------------------�­ <br /> ------------------------- ------------------- <br /> -----------------------------------=-------------------- ------------------------------------------------- <br /> (Draw existing and required.add ition.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 be Vo subtest to Workman's Compensation Idws of-California. -—___ ' " "` """`" - -- ' - <br /> Signe1K` -----------------------------------------•-------- Owner b.�t <br /> Title F <br /> BY -r ----- ------------------------------------------• ----------------------------------- ----- _ <br /> (If other than owner) <br /> FOR DEPA1tTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ ;9720- ----- - -- ----- -------------------------------------------------------------- <br /> = DATE ----- '�-------- ----:_ ------- <br /> - - - - - <br /> BUILDINGPERMIT ISSUED --------------------- ---------------------------------------------------------DATE ----------------------------------' ------- <br /> ADDITIONALCOMMENTS -------------------------- ----------------------------------------- -----------------------------------------------.--- --------------------------- <br /> ---------- ---- ------------------------------- ------------------- ---- <br /> ----------------------------------------------------------` --------------------------------------- ---------- ------- <br /> ---------------------------------------------------------------------J�----A---- - ---�-----------------------------------------1 <br /> f -- ---------------------------------- - --- '� <br /> `�� <br /> Final Inspection by r'-==jI----------•-•-n--------- .Date -- --------------------- - ----- <br /> SAN-JOAQUIN -LOCAL--HEALTH-DISTRICT <br /> { <br /> E. H. 9 1-'6$ Rev. 5M �9 '' t- <br />