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FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit Na. ----- <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compli nce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC N --------- ---------CENSUS TRACT --5-V-7-_---------_ <br /> Owner's Name ----il 1 `- eT - --------------------Phone <br /> Address --------- --- - ----- -------------------------------------------------- City ------�--------.-------`-`= , ------------------------------------• <br /> GG <br /> Contractor's Name ------- Y_.___ = _-7 -------------License # 11G- `Phone <br /> Installation will serve.. Residence 9 <br /> Apartment House❑ Commercial ❑Trailer Court !,❑ <br /> 11 Motel ❑ Other ----------------------------- -------------- <br /> Number of living units:-------F_--- Number of bedrooms ---t�-__-__Garbage Grinder ------------ Lot Size ------ <br /> Water Supply: Public System-and-name = ---------------------------•---------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe [] Fill Material ------------ If yes,type ____________________________ <br /> (Plot plan, showing size of lot, location of system.,in relation t6—wells, buildings, etc. must be placed on reverse side.) . <br /> NEW INSTALLATION: (No septic tank br seepage pit permitted if public sewer is available within 200 feet,) <br /> W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ------------_--_------- <br /> Capacity----------------- <br /> -----------••--..._...---Capacity----------------- --- Type -------------------- Material---- ----------------- No. Compartments --------- ---•-------- r <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ---------------------- <br /> L EACHING <br /> _______________-.__-_LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length --.--------------------._.-- 1. <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 C) <br /> Water Table Depth ------------------------------------------ .... Rock Size ------ --------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev, Sanitation Permit x# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---- --- ------ ---------------------------------------------------------------- ----------------------------<.--------------------------- <br /> is osal Field (Specify Requirements] _ ____ _________ _______ rY-_ `__ - � ---____-- <br /> - ----------- ---- --- ----- - ----------- <br /> ---fit------�-1---:-- -- ---- <br /> -- --------- ---- --------------- -- -= ---- ----------------------------------------------------------------- <br /> (Draw existing and require 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 /> 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 Compensation laws of California." <br /> Signed --- ------------------- -----_.-. �Q - --- ------- Owner <br /> By ------------------ rG/ Title _ ----------------------------- <br /> (If othb_r:than owner)' I <br /> r <br /> G- <br /> I ;,, -. FOR -DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. �–. ------------------------------------------------------------ DATE <br /> _3_- / <br /> - -- <br /> BUILDING PERMIT ISSUED--f-_r.,r ------------------------------------------------------------------------:----------_-DATE - -- -----------------------------------•- <br /> ADDITIONALCOMMENTS :--- -- -- ------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- i <br /> -------------------------------------------------------------------------------- <br /> ------------------------- ------- r <br /> Final Inspection b -Date .'�__' L-� ' ________- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s <br /> E. H. 9 1-'6$ Rev. 5M <br />