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r r . FQR FF10E•;SE: APPLICATION FOR SANITATION PERMIT <br /> - Permit No- -- -------- -------- <br /> -------------- <br /> /� (Complete in Triplicate) <br /> - --- -- <br /> Date Issued _2--�"---�7-- <br /> This Permit Expires 1 Year From Date Issued <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 incompliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - ly� 2 <br /> 6 J-_ ------------------ ------ ----------CENSUS TRACT ---------------------•---- <br /> Owner's Name <br /> �'. Sa_` ------ Phone � a 3 <br /> Address ------- Cit --- ----- <br /> ----------------••----- <br /> Contractor's Name --------------- -------------------- ----- ---- <br /> _ ---------------License # .5�------- Phone d 60 <br /> Installation will serve: Residence Hose,❑ Commercial [:]Trailer Court l❑ <br /> Moet 1 Other ------------------------------------------•- <br /> Number of living units-.--./----- Number of bedrooms . ..__..-Garbage Grinder ...--------- Lot Size _._____----__"_-- _-- <br /> ---------------------- <br /> Water Supply: Public System and name ----- ----------------------- ----------------- -------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom-0 Clay Loam ❑ <br /> Hardpan Adobe Fi <br /> E- ll Material ------------ if yes, type ------------------ <br /> (Plot plan, showiA tin size of lot, location of system �n relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public,se er,is available within 200 feet,) <br /> �.APACKAGE TREATMENT [ ] SEPTIC TANK'[ ] - Size-------'---=---•----------- Liquid Depth ---------------------.-----� <br /> WA..�, , I n.� <br /> Ca acity -«^- T e ` =¢ ,. Maferlal,_°------------------ No. Compartments t <br /> -------- <br /> Capacity .I -"=1 `t'r $ y.i �; `34 '�[ <br /> Distance-to-neprest: Well -----_...r !Foundation ---------------`------ Prop. Line _...------------------ <br /> Di <br /> ._._- ----- <br /> _No&'Lines ----- ---- Length of Each"liner----------------------- Tota[ Length -----------•-------•---•---- <br /> LEACHING LINE [ ] ,a ; <br /> 'D' Box ------------ Type Fllter..Mate rial ------- :��--Depth Filter Material -------------------------------------------- <br /> : Wel . - Foundation -__ ._---- . -Property Line ------------ ----------- <br /> 11 to newest: Weld-.__�___--...--____ _ -T-�r----= <br /> SEEPAGE PIT [ ] DepthJ_.}- '-_>-------- Diameter ---------_-•y--- Number -------------------- Rock Filled Yes [] No <br /> Water Table Depth ------------------------------------------------Rock <br /> Size ------------------------ ------- <br /> J4.-kDistance,fo nearest: Well ----------------------------------------Foundation -------------------- Prop. Line __-----...----------•- <br /> REPAIR/ADDITION(Prev. SarPftation Permit# --- - ---------- ------ ate ----------------------•• ) <br /> Septic Tank (Specify Requirements) ..----..-.-- � <br /> Disposal Field {Specify Requirements) .__._ - -- '`'' _7� 5"" " <br /> 1----�Q- mo -- <br /> ---- i <br /> ------------------------------------------------------------------------------------------------------------------- <br /> --- ------------- --------------------------------------------------------------------------------------------------------------------- <br /> --- -- -- -(Draw existing and required addition on reverse-side) <br /> 1 hereby certify that 1 have prepared this„cpolication and that the work will be done in accordance with San Joaquin <br /> -.., <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or icen- <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 -- ---------- -- --------------------------- Owner <br /> BY - --- ------ ------ ------ -- - -------- <br /> 1 itle .. ............ <br /> - ------------ ......................... <br /> ----------- -------- <br /> (If other th owner) <br /> 0 <br /> FOR DEPARTMENT USE ONLY 7 <br /> APPLICATION ACCEPTED BY --&----- ------------------------ ------------------------------------------------------------ DATE /- ------------------ <br /> BUILDING PERMIT ISSUED ---------------------------------- --- -- ----DATE ------ ----------------------------- <br /> ADDITIONAL COMMENTS ---------------------------------- ---------------------------------------- <br /> - <br /> - ------------------------ <br /> ----------------------------------------- <br /> ---------- <br /> -------- ---- ------------ --------------------------------------------------------------------------------------- <br /> -------------- ---------------------------- ---------[} - -- -- - <br /> �' <br /> /��`--v -� ------ ----- -------- Date --------- --------------- <br /> Final Inspection by: --- ----- - <br /> --------------- ----6-------- -- , <br /> SAN JIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />