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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. 1�- , <br /> J:: <br /> -- .....................................----- <br /> This Permit Expires t Year From bah Issued Date Issued f..:.0.__1,6 <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 <br /> made in com&plian with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .1..�.L �..._ "............................CENSUS TRACT .................----..... <br /> Owner's Name ........ �- 1�, Phone <br /> Address . ..... ..../& /• 4[�/� <br /> City .. ....... . . <br /> Contractor's Name ___... . _. ... �- .-.....,license #�, � F.i.. Phone .............................. <br /> Installation will serve: Residence Apartment House Commercial{]Trailer Court 0 <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 b Silt❑ Clay ❑ Peat❑ Sandy Loam fD--/Clay loam ❑ 121� <br /> Hardpan ❑ Adobe ❑ Fill Material <br /> ............ 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 or seepage pit permitted if public sewer 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 LINE [ ] No. of lines ------------------ --- length of eachline............................ Tota) Length .......................... <br /> 'D' Box ------------ Type Filter Material .................. <br /> .Depth Filter Material ............................................ <br /> Distance to nearest: Well ......................... Foundation .__._......_............ Property Line ....•................... <br /> SEEPAGE PIT [ 3 Depth ----- -------------- Diameter ._.. Rock Filled Yes ❑ No 0 <br /> -•--••---------- Number --------.. ---... <br /> Water Table Depth ..---•........................ .................Rock Size ............................. <br /> Distance to nearest: Well ------.......... <br /> ...............• ---..Foundation ------. ............ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit j# ----_____------------------------. _ . <br /> • - •-•--- Date ----------------------------------) I <br /> Septic Tank (Specify Requirements) -•--•------- -------------------------------- ­-------------- --•--•• _. �_...----- ....__.......... <br /> Disposal Field (Specify Requirements) <br /> -� ------------------•--------• ---------- ------------ --------------------- ..................... ............. .......... <br /> ---------------------- --------------------------------------------__----------.............................................................I................ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin , <br /> County Ordinances, State taws, and Rules and Regulations of the San Joaquin Local Heaith,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 subject to Workman's Compensation laws of California." <br /> Signed ------- • -------•----- ---- oC,l�j Owner---•- ------ <br /> BY Title --"If <br /> L!st" --------- <br /> (If ................ <br /> other than owner) <br /> FAR DEPARTMENT USE ONLY <br /> Y i <br /> APPLICATION ACCEPTED BY ....... -------'•.----------•- -- DATE .I ./�?._,7- -------------- -- r <br /> ----------- <br /> BUILDING PERMIT ISSUED _... ----.DATE ....... .......... ................ ------ <br /> ADDITIONALCOMMENTS -------•--•----------------•------- -•-------------------- •-...----...-•------------.-..._...__._... <br /> •----•---•----- <br /> --------------•-------•----------•---------- ------------------. ..---------------.-------------------------------------- ---------..............__.._..... ................ .................. <br /> --------------- <br /> ______________________________ ____ _.._ _ _ ik.___.._-.... __...._ <br /> FinalInspection by: - ,-- ,-••- __ _ ________________________________________________________________Date . ./. - -------•---------_---- <br /> Efi 13 2!i 1-613 Itev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> i <br /> I <br /> ;1 <br />