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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> , ff 6S P <br />.................................................... Permit No. ..7�`...._:. ...._ <br /> (Complete in Triplicate) <br /> .............................................. <br /> ..----_------------------•.....--..... This Permit Expires } Year From Dato Issued <br /> Date Issued <br /> Application is hereby made to the Sun 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. 544 and existing Rules and Regulation's. <br /> 108 ADDRESS/LOCATION ,..1 ?. . _ ..--.�...�................CENSUS TRACT .......................... <br /> Owner's Name .... .....................................------- ................Phone .................................... <br /> Address �1a� ��/�' ' a -.-city ._�.:....................•-- •-•-•-•-•---.........._...._... <br /> .. ................... <br /> '01 <br /> Contractor's Name ... nom., ; .--T"`f�' �-...A-�-...... :............License # ,e�V -. Phone .....---...................... <br /> Installation will serve: Residence [Apartment Houseo Commercial ❑Trailer Court <br /> Motel ❑Other .-.--_--•---------------- -_--•--------- <br /> Number of living units:....1------ 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❑ Clay ❑ Peat❑ Sandy Loam Clay Loam_M <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 orsee ge pit permitted If ubiic/ sewer is available within 200 feet,} <br /> If. <br /> 1._. X / <br /> PACKAGE TREATMENT [ ) SEPTIC TANK Size. ,?.._, ... fi7-------- Liquid Depth ...���................. <br /> Capocity 9.a.0.. Typedl--� ! .. Materiai.-&-a!„' ...-- No. Compartments _.;' .......... <br /> Distance to nearest: Well .-......... A.. �__ .......Foundation ..._1Q..�-_---_-. Prop. Line ..S.............. r <br /> / S <br /> _ <br /> LEACHING LINE [ No, of Lines --_---r............. length -of each lme...._..._ (....f..--.._. Total length -_�_�...........__.._... tj <br /> 'D' Box ............ Type Filter Material .___$_.....Depth Filter Material .--1_ '.'` ° <br /> f• Z <br /> Distance to nearest: Well ......�G© . ... Foundation ..___/�'.............. Property Lane ._..........._...:_..___ <br /> SEEPAGE PIT Vl Depth ...._cry��1... Diameter .,. ri Number ----------Z............... Rock Filled Yes � No ❑ ' <br /> Water Table Depth ......... .YQ..-...-----•-- ......... Rock Size .lp. <br /> 1 ....X..3.__-_-- <br /> If <br /> -- -- ----.. G <br /> Distance to nearest: Well ........... -.- .D.................Foundation Prop. Line ... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---_-----------___.................... Date ........................-.-.......I v+ <br /> SepticTank (Specify Requirements) .............................................................. ....................----..................................................... T <br /> Disposal Field (Specify Requirements) I.'�....�.......--^. -... - <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, 1 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 ...- -.i`.,.a...<<^'- .-._.......-......------------------: <br /> (if other than owner} <br /> F2f DEPARTMENT USE ONLY <br /> rte . . ... - .. _ <br /> APPLICATIONACCEPTED BY ..................... ......-`---------•--•--•---...--•-•- ......................................... DATE --..../ ---- • ------- <br /> BUILDING PERMIT ISSUED ....... ... : .............................. <br /> ADDITIONAL COMMENTS ... . �.._.. ....... <br /> j.. � <br /> ..........::::::::::::::::::::::::::::::.......... -:... � .. ......-. .....---.--•- <br /> -�. - <br /> :. .. , <br /> Final Inspection by ". ..�.. <br /> ................................................Date ................... <br /> .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.1-3 24 V68 Rev. SM 7/723 M <br />