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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 4. (Completl�in Triplicate) Permit No. _2_,_` ------ <br /> k- N. Dt to Issued <br /> -__-__----_--._.- __.--___- This Peripit Expires T Year From Date Issued <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 c 1lance with ourity Ordinance No. 549 and existing ules pnd Regulations: <br /> JOB ADDRESS/LOCATION .__..., °_— � � <br /> ----- --- <br /> CENSUSTRACT <br /> Owner's Name ?a/� Phone '_ <br /> Address ---- .----- -(r' ----Ale- ------. Cit tv/�' �!� . -------- <br /> -- <br /> - -------------------------- ----------------- -- E]------------------ <br /> Contractors Name --------------------- License # <br /> - <br /> Installation wall_serve:�..�-,.r.----Residence-PApartment-HousMe.- -Commercial-I❑Trailer-Court• ,G-- f <br /> .M_otel ❑Other ------------ �� ---------------------------- <br /> / Aes <br /> Number of living-units`:j------- Number,of bedrooms �--_lGarba_ge Grinder --------.- Lot Size ___ ----------- ---------------- <br /> Water Supply: Public System and name ----------------------•------- I�-------- -----------------------•-----------------------•--------•----•-Private <br /> Character of soil to a depth of 3 feet: Sand [:] Silt❑ Clh y ❑ Peat❑ Sandy Loam,' Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type „.. ___ i <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) I <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size-_------ ---------------------------------------- Liquid Depth”? V <br /> } <br /> I Capacity -------------•------ Type --------------I M"t'erial-------------------=--- No. Compartments ---------- - -•---••-• lSl <br /> Distance to nearest: Well -_----_._-:-_5 __._--_-:.:.._ _Foundation ---------------------- Prop. Line ---- <br /> LEACHING LINE ( j No. of Lines -------------------- -- Length of each line-- ------------------.------ Total Length ------•---------- , <br /> D' Box -------- <br /> --- Type Filter`M-afei ial�__•----------------'Depth Filter Material --------------"---------'----------------- <br /> i <br /> Distance to nearest:.WeII.__--_____________I -__. Foundation Property Line"------l................. <br /> SEEPAGE PITT [ ] Depth -------------------- Diameter -------_ - Number .--------•-------._--''Rock Filled, Yes [J No Ct <br /> y = - <br /> # i Water Table DepthRcSize <br /> - _ -----------: I I` - . <br /> #---------- <br /> ; <br /> ___ ___ __ ' <br /> '•-)PropDiitanoe.to nearest• Well _- �h Line -----I <br /> ----------------- <br /> s E + <br /> REPAIR ADDITION(Prev.:Sanitation Permit# -______^_'__________________lI!�_____,_. ----- Date IJ�------ ----- <br /> (Specify Requirements)'------ ----------- - - -s -Septic Tank <br /> ---------- <br /> Disposal Field I pecifY Requirementsl --------j------- <br /> - I - s <br /> --- : <br /> ../ <br /> (Draw existing and required addition on reverse,side)�� <br /> I hereby certify that`I havel'prepared this application and that the work will, be done in accordance with Son Joaquin <br /> County Ordinances, State.-Ld s, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature.i ertifies the.following: 1�. <br /> "I certify thpf in the perfoi'manof the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become'subject' W km I 's Com ensation laws of Ca.lifornia." ' ° I <br /> c <br /> Signed ----- .' '' l ---_:==_---_--=-===-- --=----- Owner.4 3 <br /> BY - ------- ---- ------------- I� Title I -- <br /> i(If other than .owner) <br /> i r , <br /> F R DEPARTMENT USE ONLY + <br /> APPLICATION ACCEPTED BY ..__.Cr✓G ___r ---- --- ----. �I.------------------------------------------ DATE __._ =-1 ----------- <br /> BUILDING PERMIT ISSUED ------ = DATE - ---- ----------------------------- <br /> ADDITIONAL COMMENTS ---------_ ---_. _----.:_--- <br /> ------=-------------------------------------------- -------------- ------------ <br /> �t ; , � � -,� - <� ----------------------- - <br /> -- ----- ------ ----- - -- ------------I---------------------------- ----------------- <br /> ------------ i:------------------ ------------------ <br /> �- <br /> Final Inspection by: � --------_--- <br /> I ----------------------------Date � �---------- ---- ---- -------- • <br /> SAN JOAQUI LOCAL HEALTH DISTRICT <br /> t <br /> E. H. 9 1-'68 Rev. 5M 4 <br />