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FOR OFFICE USE: <br /> APPLICATION ICOR SANITATION PERMIT <br /> Permit No. ._ <br /> (Complete in Triplicate) <br /> ---------- ---------------------------------------------- <br /> --------------------------------- This Permit Expires 1 Year From Date Issued Date Issued - -------,------ � <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in coomplidnce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ :.: ----------------------�J- [ CENSUS TRACT <br /> y y� ff <br /> Owner's Name 1� > LS---------------------------------------------- ----= Phone_�_W°'V1 U <br /> Address - -----1`�.� --------�------�� , _4��V�--------------------------------------•--- City A— ''"-'------------------------------------- <br /> Contractor's Name ----------------------------------------------------------------------------- -------License # ------------------------ Phone .............................. .. <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ,❑ <br /> Motel ❑.Other -------- --------- ------------------------- <br /> Number <br /> -----------------------Number of living units:_________ Number of bedrooms r�'____Garbage Grinder ----�---- Lot Size .�-r'P__�_�2-��___________. <br /> Jk <br />( Water Supply: Public System and name <f—tPJ__��-------------------------------------------------------------------------------------------Private ❑ <br /> k Character of soil to a depth of 3 feet: Sand❑. Silt❑ 7ClaE] Peat E] Sandy Loam ❑ Clay Loam:D <br /> Hardpan E] Adobe 'it Material ------------ If yes,type ---------------------------- <br /> (Plot plan, showingsize of lot, iocation.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 [ I SEPTICTANKi-i"- r Sizes _ Qx___1-4-------__ Liquid Depth -------------___~__---__ W <br /> Capacity_!9_Fr0_ 9LType -------------------- Material----C----------- No. Compartments 1�_----------- <br /> Distance to nearest: Well Pro ------ i'`� <br /> - ----�{�-----------------Foundation --------- -- -- - P• Line ----•----------- <br />' - t <br /> LEACHING LINE [t.K No. of Lines--'-----�Y----------- Length of each line__.____ _Q____________ Total Length __��b_______________ <br /> 'D' Box ____-_ Type Filter Material ____________________Depth Filter Material --------------------.------------.___-___--- ` <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ---------._-_-_________ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------- ---- Prop. Line ---------------------- <br /> REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------------------------- ------------------ -------------------------------------•--------------------------------------------------------- <br /> Disposal <br /> ------ -------------------Disposal Field (Specify Requirements) -------------------------------- ------------------------------------------------------•--------- ----- <br /> --------------- --------------- --------------------------------------------------- <br /> ----------------------------------------------------------------------- -------- -- <br /> ---------------------------------------------------------------------------------------------- ----- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> t 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 erformance of a ork for which this permit is issued, 1 shall not employ any person in such manner <br /> N <br /> as to become b'e o Workm s C p sation I ws of California." <br /> Signe - -- - ---- --- - -- - -- - -- - - ------------------------------- Owner <br /> BY --------- ---------- ---- -------- -------------------------- ----------------------------------------- Title ----------------- <br /> (If other than owner) <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE ----..--- � � ��--------- <br /> FBUILDING PERMIT ISSUED - ---------------------------------- -----------------------------•---= ------._DATE -- ------ ------- ---- -------------.. <br /> ADDITIONALCOMMENTS ------------------'------------------------------------------------------------------- ------------------------------------------=--------------------------- <br /> --------------------- ------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- <br /> i ------- ----- ------------------------------------------------------------ -------------------------------- ----------------------------- ----------------------------------------- <br /> -------------------------------------------- = <br /> Final Inspection b Date F 1 ' <br /> P Y <br /> SAOOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M' <br />