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FOR OFFICE USE: <br /> --------- APPLICATION FOR SANITATION PERMIT <br /> ------ (Complete in Triplicate) Permit No. <br /> -------- ----------------------------- <br /> A 25 �1 <br /> ------------------------------------------:--------------- This..Permit Expires 1 Year From Date Issued Date Issued &, :4 <br /> Application is hereby made to the Son Joaquin Lotal 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 /> .09 <br /> ------- - - ---- -- - ------- -- .----------------------------.-CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCATI - ------------ <br /> Owner's Name ------ --------- <br /> -- ---------------------------------- -------�­----- Phone 71ar- ------ <br /> Address -------------------- ----- -- ----- f <br /> ----------- ------- --- --------------�,­-Cit y ---------------------------------------------- <br /> Contractor's Name <br /> -------- ---- --------- 4 - --- - License ce n s e AvrZ1- - Phone :9---5W.7--- <br /> Installation will serve: Residence.(]-Apartment House,E] Commercial :❑Trail' <br /> er Court E] <br /> Motel'[j,Qth J------------ <br /> Number of living units:_________-_ Number of bed rooms, 01r� <br /> Garbdge Grinder ------------ Lot Size ----------- <br /> Water Supply: Public System and-I'hame -----------------------------i-__e----------------------------------- ---------------------------------------Private <br /> F 101 <br /> Character of soil to a depth of 3 fe'et. Sa`n_d�05irff-[] Clay E17 Peat[:] Sandy Loam ,E] Clay Loam 'o <br /> Hardpan E] Adobe Fill Material ------------ If yes,type --------- ------------------ <br /> (Plot plan, showing size of lot, location lof-system-ih-relat-ion-to-w6lls, buildings, etc. must be placed on reverse side.) <br /> tank" .I <br /> NEW INSTALLATION- (No septic tank or (NI <br /> TANK <br /> pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT SEPTIC4k�TAN Size---------- <br /> ------------ --------------­ Liquid Depth -------------------------- -- <br /> A <br /> Capacity --------------- --- Type ------------ Material------- -- -------- No. Compartments ------ ............... <br /> Distance. to I I - (A <br /> Inearest: Well -------------- ---------1------Foundation --------- ------------ Prop. Line ---------------I------- I <br /> LEACHING LINE No. of Lines --------- -------- Length4o e�chlline-------------------- ------ Total Length ----------------- <br /> DIN 'D' Box'-,----[----- Type ilter Material ------- -------Depth Filter Material -----------------------•--....-----.----•---- <br /> . <br /> ---------------------- --------- <br /> qI k <br /> ""Distance o EaresrT f: e -------------- Foundation on ------------------------ Property Line -------------- .......... <br /> SEEPAGE PIT Depth <br /> ------- ------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> VJ <br /> Water Tabld Depth -Rock Size ---------- --------------------- <br /> J ------ ---------------------------------------- <br /> Distance to,hearest: Well <br /> ---------------------------------1-----Foundation -------------------- Prop. Line--------------__.----. <br /> REPAIR/ADDITION(Prey. Sonication 0 -------- ------------------------------- --1 - Date ---------------------------------- <br /> I , N <br /> Septic Tank (Specify Requirements------4 <br /> -------- ---------- <br /> XQV - ---------------------- ------------- ----------- <br /> Disposal Field (Specify Requiremekts) ---- ---------- <br /> 3_�? is -------------- - <br /> ------- ------------------------ - - � X <br /> J---------------- rc�-,0 775 ----;------ ,----F r _14:01 <br /> --------------------------- <br /> --------------- <br /> ---------------------- <br /> ----------- -------------- ------------------------------------------------------------------------------------------------ <br /> ► (Draw existing anti require'8-a'iditio'n on reverse side) <br /> I hereby certify that I have prepared this applicatiorl and that the work will be done in accordance. with San Joaquin <br /> County Ordinances, State Laws, and iiles ca-hd Rbgulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following! ie,5 <br /> "I certify that in the pI <br /> erFormanc 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 la W's of Cafil'ornia <br /> Signed ------- ---- - ----------------------------- Ow* ner <br /> By --- ------ - ---- ---- ........QAP—M <br /> - ----- ----------- ------------------- Title --------- <br /> Ai If'kot 2rl.Xc n -------------- ------------------- <br /> (if other n own r) <br /> LFI.�11.41 USE' ONLY <br /> APPLICATION ACCEPTED Bk- -- ---------- ----------------i ---- --- --- ------ --- DATE,— ------------- <br /> ---------- ------------ <br /> BUILDING PERMIT ISSUED - -- - ----- ----- --- <br /> ADDITIONAL COMMENTS 1111 --.. .. (( ----�i _-._��----)PATE - --------- -11----- --- ------------- <br /> �tNTS __ .0--- L� --- i� I <br /> f <br /> ----------------7------------------i------------------------------ --- -------------------1---------------------------- ---------------- <br /> <- --------- ------- - ---------- ------------------------------------------ <br /> ---------- ------------------------I <br /> -----------------------I ---------- ----------- ------ <br /> ------------- --- - ---------- ---------- <br /> ------------------- ---------------L ----------------------- ------------- -------------r------------------ -------------- -b- <br /> lilfa---- ------------------i-------- ----------- <br /> Final Inspection by: <br /> ----------- <br /> SAN JOAQUIN LOCjJ -,EALTH DISTRICT <br /> E, H. 9 1-'6$ Rev. 5M <br />