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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT q <br /> A-- Permit No: <br /> ------ -------------- ---------------------------------- (Complete in Triplicate) f <br /> -------­-- - ---------- -------------------- <br /> Date Issued - ------- <br /> _ I _ - This Permit Expires ] Year From Date Issued -70 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct Jand,install��� <br /> the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> (e'27, ' ��) � w4 � <br /> OB ADDRESS/LOCATION lor <br /> Owner's Name ------------------------ --------------------Phone-------------------•-------------•--- <br /> y -- X11-��---�/�m-------- ---------------------------- - <br /> j/� k f �_r1U 1�eJ - -- - city <br /> Address s/Il: ! ( _ D. _ e�i�a=/238... <br /> Contractor's Name---. -------------- -- --------------------------------------------------------------License # ------- -:---------- --- Phone -----------------------.------ <br /> Installation will serve: Residence ❑ Apartment�H�oyuse,0 ICommercial ❑Trailer Court ;❑ <br /> Motel ❑Other --- - _______________ <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❑J 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.) N <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> L - u <br /> PACKAGE TREATMENT { ] SEPTIC TANK:[� Size------- ------- Liquid Depth p ------ -----'---- ---- <br /> --- <br /> Capacity 19M------- Type j&MJ---- Material No. Compartments ---------------------- <br /> Distance to nearest: Well --------�0---------------------Foundation ------la---------- Prop. Line ---1-------:--_-_-•- <br /> LEACHING LINE [ ] No. of Lines ------9--------------- Length of each line------3U--------------- Total Length __-jgd-- -••---------- <br /> 'D' Box --------- Type Filter Material Sgp:J�-----Depth Filter Material -----------______ -----------____________ <br /> Distance to nearest: Well ______�Q------------ Foundation ----- ---------- Property Line ----- ........ <br /> SEEPAGE PIT [ ] Depth --------- ---------- Diameter ________________ Number ----------------- ---------- Rock Filled Yes ❑ No 0Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well -------------------------- -------------Foundation -------------------- Prop. Line ----.----.------.----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------------------ ---------------------•--------- ---------------- <br /> Disposal Field {Specify Requirements) ---------------- ------------------------------------------------------- <br /> -----------------------------=---------------------- <br /> ------------------------------------ <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 Son 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 laws of California." <br /> Signe ---------------------------------- Owner <br /> ;title -_----------- ---------------- ------------------------------------ <br /> (If oth t an owner) <br /> FOR DEPARTMENT U O Y <br /> APPLICATION ACCEPTED BY ------ - . DATE Gr <br /> ------------------ --------- <br /> BUILDING PERMIT ISSUED ----- ----- --- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------- --------- ------------------------------------------------------------------------ --------- ----------- <br /> -----------------------------------------r, -- - t,_i <br /> - - ------------------------------------------------------------------------------- <br /> ---------- --------------- ---------------- --------------------------------------------------- <br /> ------------------------------- -------------------------------------------- <br /> ------ <br /> - <br /> --- ----------- - -- <br /> ---------=------- <br /> Final Inspection b ___ -----.Date -------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH !STRICT <br /> G 14 0 1_'AA RPv- 5M <br />