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°FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT <br /> --_---_I PZ Permit No. <br /> - ------------- - - ------ ---- - - <br /> ---------------------------------- - (Complete in Triplicate) <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to thelSan Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in complia e with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION c 7�� s - ----- -- CENSUS TRACT <br /> Owner's Name -------Phone . <br /> -------- yr-�------- -- -- - //���" � ��//�� <br /> Address ---------------------------ef?-.7' --- Y <br /> - ----------•-- ------`-------.License # ,�00 ----- Phone _�tL66' '---- <br /> Contractor's Name ----------------"- -- ------•--------- ---- <br /> Installation will serve. Residence KApartment House❑ Commercial ❑Trailer Court I❑ <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:------.--- Number of bedrooms ____ __ O F <br /> -vGarbage Grinder ____________ Lot Size ---------- ---------- <br /> Water Supply: Public System and name ---------------------- ----------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of.31feet:.----_Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam.❑ <br /> Hardpan E:]-.Adobe Fill Material ------------ If yes,type ___________________________ <br /> iPlot plan, showing size of lot, location of system in relation-40,,keIls, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septia'tank or see.page_pit_p_prmitted.,if_publicysewer is available within 200 feet,) <br /> Li <br /> PACKAGE TREATMENT { ] SEPTIC TANK;[ ] Size__________________________________.------------ Liquid Depth p --------------------- --- O� <br /> Type <br /> `. <br /> "� <br /> -------------------- Material-----------`------- No. Compartments ----------------- <br /> Capacity -=------ ----- -.-- <br /> t t: Well ---------- ------ •------------Foundation,- .F <br /> = -------------- Prop. Line <br /> Distance to nearer--------------- L gthr <br /> LEACHING LINE [ ] No. of Linesri <br /> �of�each line---------------------- ---- Total Length ---_-----------.------_----- <br /> 'D' Box -E-,--------- Type Filter Material --------------------Depth Fitter Material --------------------------------------------0% <br /> � <br /> j. <br /> Distance to nearest: Well ------------------------ Foundation ------------------------- Property Line, ---_---------.-----_..._ <br /> ' " ____ Number ___________________ Rock Filled Yes ❑ No CIO <br /> SEEPAGE PIT [ ] Depth D�ameter A <br /> iWater Table Depth ---y------------------------•--------_---.;_-:Rock Size ------------------------ ------- j <br /> � ` • si* s <br /> Distance Ito nebrest.-Well � ______. _ '"`Fo6ndation� _-------------- <br /> --- Prop. Line ______________________� <br /> M <br /> y �. <br />[ REPAIR/ADDITION(Prev. Sanitation Permit# ------------ Date ----- ) A <br /> Septic Tank (Specify Requireme i - <' ._,_'_ -- ------------------ ---------- ; <br /> Dispos❑ Field (Specify Requirements) y---- -"�4 '�"` -------------- -------------- <br /> /� -- -- ---- - --- <br /> "LL <br /> ---------------- - <br /> --- e- -'_ - <br /> - -- - -- v <br /> - - "- --- - ------ <br /> ------------------------------- <br /> T--x----------------------------------'----- ----------- <br /> ------------------------------ --- - - - - - ------------------------------- -- ---------------------------------------------------------- <br />' (Draw existing and required addition,on reverse side) <br /> f 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 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 Compen3ation laws of California: <br /> Signed -- ---------------------------- -------- 1. ---------------------------------- Owner <br /> BY -- ------ <br /> ( -----------• Title ---- - '---------- ---------------------------- - <br /> (If other n owner) <br /> EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- -------_-- ------------------------------------- DATE ------A-nA 77/--------------- <br /> ----- -- - ------- ------------- <br /> BUILDING PERMIT ISSUED ----- - -------------------------------DATE ------------------------------------------- <br /> ---- --- ------ - -- <br /> ADDITIONAL COMMENTS ----- --- -- - --------------- ----------------------=------------------=---------- ---------------- <br /> ---------- <br /> -------------------------------- --------------------------------------------------- <br /> ---------------------------------- <br /> --- - <br /> ------------------------------------------------------------------- <br /> ---------------------------------------------------------------------- <br /> ------------------------------------ ------------------------------ -- --------- <br /> Final Inspection b -------.Date ---- <br /> ------------ <br /> - f Z <br /> ___ �-- - <br /> IN <br /> SA JOAQUIN LOCAL HEALTH DISTRICT `U <br /> w1-'68 Rev. 5M fl" Iz <br />