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FOR OFFICE USE: pppLICATlON FOR SANITATION PERMIT <br /> Permit No. <br /> ------------------- - -- <br /> -----------•----------------"-""" (Complete in Triplicate) <br /> Date Issued3 <br /> ------------------------- <br /> --- <br /> This Permit Expires l Year From Date Issued <br /> and <br /> e work <br /> rein <br /> Application is hereby made to the San Joaquin <br /> Joq GlHealth District mti tlhs <br /> application is made in co piace wih CounttyOdnana permit <br /> and existing RulesandRegulation : <br /> described. This <br /> -----CENSUS TRACT -------------- <br /> JOB <br /> ------------JOB ADDRESS/LOCATI -- --- ------------ """""" <br /> Pone <br /> - -------------------- --- <br /> Owner's Name ----- - ------ ----------- - ---- ---- -----------------•-- <br /> ` City -Z -- -- ----- -- <br /> ---- - ------- <br /> J —� ' �License # p Phone - <br /> ---------- <br /> -�-��-�--- - <br /> Contractor's Name _.- ---------- - ----- --------- --"- <br /> Residence �l tment House❑ Commercial ❑Trailer Court [1installation will serve: pary <br /> Motel ❑ Other -------------------------------------------- <br /> rooms <br /> ----------------------------- ------ -- <br /> F Number of living units:.__._----- Number of bedrooms --- ----- Grinder ______-____ Lot Size - y_J <br /> Private <br /> __ � � -------- --- - - •-"--=------- -------------- a _. <br /> Water Supply: Public System and-name --- ------------------. --- ❑ Clay Loam :❑ <br /> [] <br /> e Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam <br /> Adobe ' Fill Material ------------ if Yes,type --------------------- ----- <br /> Hardpan E] <br /> size of lot, location of system•in relation to wells, buildings, etc. musfi be placed on reverse side.) <br /> I: - <br /> i tA <br /> [Plot plan, showing t, <br /> i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ' SEPTIC TANK'[ ] � �` Size--- -----•------•------ --------------------- Liquid Depth --------::,------•----.----- <br /> € PACKAGE TREATMENT { ] <br /> Material----------------- -- No: Compartments ------•----•-----•---- <br /> Capacity -------------------- Type .----------------- r� <br /> Foundation'% ------------w--------- Prop. Line ---•--------------•--- <br /> Distance to nearest: We _- <br /> Length of each line----- ------------ Total Length <br /> LEACHING LINE [ ] No. of Lines- <br /> 'D' <br /> ines-: •- <br /> _De Depth Filter Material -------------•--------------•--------------- <br /> `D' Box -------•----- TYpe Filter Material -----------------•- p <br /> r f <br /> Line------ Foundation ----------------------- <br /> Property Lin - <br /> r Distance to nearest: Well ----------------- �, <br /> Diameter Number _ - " Rock Filled Yes ❑ No iC <br /> SEEPAGE [ ) p ---- <br /> ---------------- <br /> Water Table-Depth ---------------------------------------------- <br /> Distance <br /> ------ -------------•- --Rack Size ------------- -----------­------ <br /> Water <br /> -------•-Foundation ------------------- Prop. Line _..._. <br /> Distance to nearest: Well __________________"---_- - 4 <br /> Date --------------------- -•=-=------1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------- ------ <br /> Septic Tank (Specify Requirements -------------- --- w <br /> 4�1 <br /> Dis os� Field (Specify_Requirements ------------------ <br /> - - --=------ -- -- - -"----- -- -"--- " <br /> ----- - ---= -- - <br /> ---------------------- ------------------------------------------ --------------------------------------------------- <br /> (Draw existing and required addition on reverse si e <br /> h Son Joaquin <br /> I hereby certify that I have prepared this application ethat <br /> oF the San Joaquin local D strctnHomece town r or I can <br /> County Ordinances, State Laws, and Rules and Regulations <br /> sed agents signature certifies the following: arson en such manner <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any p <br /> as to become subiect orkman,s Compensation laws of California." i <br /> Owner <br /> Signed ------ <br /> �_ <br /> ----- --------- <br /> --- - ----- <br /> Title ---------- <br /> BY (If a�ter than owner) <br /> R ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _----------- _ _ __ " " <br /> ----- ----------------------------------------------- <br /> ------- DATE _._:_�_�'�f'=T�- -------------• <br /> - --- - --- - ------- --------------- - - ------ -------- ---=--- ------ --DATE -- --- ---- •----- --------------------•-- <br /> BUILDING PERMIT ISSUED _------ ----- --- <br /> - <br /> ADDITIONAL CO ENTS ----- - -- ---- --------------------------------------------------------------------------------- <br /> -------------------- <br /> -:3-We `=7.- -------- �- + r <br /> - --------------------------------- ---- ---------- <br /> -- ------ ----- <br /> -- - Date ------71 <br /> - - ------------- <br /> Final Inspection b ------------------------------------------------------- <br /> E. <br /> " - " <br /> ---------------------------------- <br /> N J QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />