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FOIL OFFICE USE: ' APPLICATION FOR SANITATION PERMIT <br /> ------ ---------------------------------------------- <br /> (Complete in Triplicate) Permit No. :7fJ <br /> ---------------------------------------------------------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------ -rT�Z,,� L Oh1E T/(' 1G----. -----------------------------CENSUS TRACT ----- 5� <br /> Owner's Name .__L� �a-� .1�' s 1±./. c" ---------------------- ---------------------------------Phone --!_M_42_--Q9..5C.?------ <br /> Address __17r,915----- ��� - City <br /> ------------------------------ <br /> Contractor's Name ------------ ---------------------------------------------------------------- -------License # ----------------------- Phone ----------------------....... <br /> . <br /> Installation will serve: Residence (<partment House❑ Commercial ❑Trailer Court ❑ <br /> / Motel ❑Other -------------------------------------------- A t <br /> Number of living units, ---/ Motel <br /> Number of bedrooms Garbage Grinder ,// D X a-- f <br /> Ab Lot Size ----------------------------------••-------- <br /> Water Supply: Public System and name -------M1_U'__7.�------W4544..-------------------------------------------------------------Private [po" <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [" Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <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 /> V <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -------------------------- ?„ <br /> Capacity -__�Q�_---_-- Type --------�-p------ Material�' G '�' % No. Compartments ------ ..... <br /> Distance to nearest: Well ------7�____________..•______-Foundation _.___-� .------- Prop. Line ----.40________ "} <br />? LEACHING LINE [ ] No. of Lines _______+ -_________-_ Length of,each line_________ �,r______ Total Length f�/ --- _ �_______...__ <br /> I 'D' Box ------------ Type Filter Material Depth Filter Material ______ __ . __ _ <br /> > R <br /> Distance to nearest: Well _.__.:-.: _________ Foundation __ __- ?, __------- Property Line ____ --------------- <br /> SEEPAGE <br /> --.'_-__ .SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled {Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size --------------- ---------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _--.----------.--_-_-_-------- <br /> Septic <br /> -_-_- -----Septic Tank (Specify Requirements[ ------------------------------------------------------------------------------------------------------------------------------------------- N <br /> 701 <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 Lwork 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 ub[ect to Work R rn's mpensation laws of California." _- <br /> Signed -- -_-_-___. Owner <br /> BY --------------------------------- -- --------------- - ----------------------------------------- Title ---------- ----------- ------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .-_777R_!0------------------------------- - ---------- DATE ------ ------------------ <br /> BUILDINGPERMIT ISSUED -------------------------------------------------------------------------------------------•--------------DATE ------------- ----------------------------- <br /> ADDITIONAL COMMENTS _ -------------------------------------------------------- <br /> ------------------- --------------------- -------------------------------------------- <br /> ------ <br /> -------------------- -- -- ---- -- -- ---- -------------------------------------------------------------------------------------------'- <br /> ------------------------ ------------ ---- -- ----- - <br /> ---- -- --------- ---- - - ---- - - - -- ----------------------------------- --- -// --- -------•------- <br /> Final Inspection . ---- ----------- ----- --------------------------------------Date <br /> y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H..9 1-'b8 Rev. 5M <br />