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FPR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------- (Complete in Triplicate) Permit No. <br /> ------------------------------------ -------------------- <br /> -------- ----- This Permit Expires 1 Year From Date Issued Date Issued Z. _7=_7- <br /> Application <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 /> JOB ADDRESS/LOCA T ON .---p�,� -_.�, (�'., ----��--- ---4.0t__,� NSUS TRACT -------------------------- <br /> Owner's Name a - ----- ----- - --Phone:------------------------------------ <br /> Address ----------- � Q .-------------------------- city ------•---------- --------- <br /> i <br /> Contractor's Name ---- -- ---------- JJ'l,Q --------------License # ------------------- <br /> ---•------ ----- -- - - ----- Phone ------------------------------ <br /> Installation <br /> -- - ---- <br /> ------------------ <br /> Installation will serve: Residence.PApartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ----- ------------------------------------- / <br /> Number of living units------------- Number of bedrooms _-3_._---G Garbage Grinder ___I_____ Lot Size _�,�_ __ _Q_-__ __.___- <br /> Water Supply: Public System and name ------� . -----------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand' ] Silt 0 Clay ❑ Peat <br /> ❑ 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 public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT <br /> { ] SEPTIC TANK Size------------------------------------------------ Liquid Depth ---- <br /> /._ �-------____-- <br /> Capacity .act_ ype ---°________________ Material No. Compartments <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ---------------------- <br /> _ <br /> f <br /> LEACHING LINE [ ] No. of Lines _S ----------------- Length of each line------ ----------.- Total Length --2-7-�--__._.__ <br /> 'D' Box ,)<- --_ Type Filter Material ____________________Depth Filter Material ---___________________________-_____--_-__._ <br /> Distance to nearest: Well ________________________ Foundation --------- -------------- Property Line ____-_____________._.___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <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) -------------°----------------------------.--------------------------------------------------------------------------------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 /> "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 ------------ --------------------------- ----------------------------------------------------------- Title -------- --------------.------------------------------------------------ <br /> (If <br /> _(1f other than owner) <br /> O DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - `- -------------------- --------------------------------------------------. DATE ---- <br /> BUILDINGPERMIT ISSUED ------------------------ --------------------------------------------------------------- ----_DATE - ----------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------- ---------------------------------------------------------------------------------------------------=-------..._---------------- <br /> -- --- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- ------------------------- --------_----------------------------------------- ---------=------------------------------------------------------------------------------------------------------ # <br /> ----------------------------------- <br /> �� <br /> FinalInspection by: ---------- -----------------------------------------------------------------------------Date l�/ -_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9- 1-'68 Rev. 5Mi <br />