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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No. -------------- <br /> (Complete <br /> (Complete in Triplicate) <br /> --------------------- TFi Vfi-r ntt Expiresa Year from �Issued <br /> Date Issued .S-.L5__-_ v <br /> Application is hereby made to the San Joaquky-Local Health District for a permit to construct and install the work herein <br /> described. This application is main co fiance with CoWty Ordin ce o. 549 and existing Rules and Regulations: <br /> 9 J <br /> 07 <br /> Q,.q <br /> fvliw4-T <br /> ----F------------------CENSUS TRACT -------------- ----------- <br /> JOB ADDRESS/LOCATI�O1432,21-M0,019-0 <br /> 4z, . � QO r, <br /> Owner's Na -----------------0_1 C__ --- ---- ---------- --'-- ---- <br /> -------Phonel ��-_Y&-/--------- <br /> � Q'yf_J City ------ - - - -V Address ---- - - -- ----/ <br /> q� <br /> Contractor's Name - -- ------------------------------ -----------License #l --- Phone . _F.e 0.7 <br /> Installation will serve: Residence XApartment House❑ Commercial []Trailer Court ;❑ <br /> Motel ❑Other -----------------------------------------------/ <br /> Number of living units:_____/. Number of bedrooms ___/___,_.__Garbage inder --�____-_- Lot Size -___.____.________________________________ <br /> •------------Private <br /> Water Supply: Public System and name --- .----- --Aw�p--`' F­1Character of soil to a depth of 3 feet: Sand❑ Silt❑-" ,Clay ❑ Peat❑ Sandy Loam K Clay Loam X <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type _-_-______________________ <br /> (PI'ot plan, showing size of lot, location of 'system in relation to wells, buildings, etc. must be placed on reverse side.) N <br /> NEW INSTALLATION: (No septic tank or seepage:pit permitted if public skWer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------_----------.____-.------------ Liquid Depth _--.---_____-._- ____-.-- <br /> Capacity ------------------- Type ------------------- Material---------------------- No. Compartments ----------•------•---- <br /> Distance to nearest: Well ------------------------------_.,..Foundation ____________________ Prop. Line ----------------_---- <br /> LEACHING <br /> __ _--.___-___.-__LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length -__-_--__-._-_--___-_----_- <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 0 <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 /> Disposal Field (Specify Requirements) ________ _____ <br /> - -------------- ------ -- ----------------------------------------------------------- <br /> ----------------------------------------------- - ----- ---e---- ---------------------------------------------=------------------------ <br /> ------------------- --------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing..and:-req uired 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation I*s of California." <br /> Signed ---- -- -- ---- ---- - ------------------ Owner , <br /> BY ---- <br /> Title . ��%w1-� <br /> -------------- ---- ------------------ <br /> (If oth an owner) <br /> - <br /> AOR VEPA*TMENT USS''ONLY <br /> APPLICATION ACCEPTED BY .--------------------------- � _ 4 DATE °�=-j„�-IJ------------------- <br /> BUILDING PERMIT ISSUED - ' = -------DATE <br /> - ---- -- ------ <br /> ADDITIONALCOMMENTS ------------------------------------ ------------------------------------------ -----------------------------------------=------------------------- <br /> --------------------------------------------------------------------------------------------------- --------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- -- ----- <br /> ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------- ----- --- --- ------- <br /> FinalInspection by: -----------------------------------------------------------------•-------------------- -----Date ----- =" <br /> SAN JOAQUIN LOCAL HEALTH DIST ICT <br /> E. H. 9 1-'68 Rev. 5M <br />