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FOR OFFICE USE: ' �? <br /> _J'-/7,7/ Jr _!ra APPLICATION FOR' SANITATION PERMIT 7a <br /> --------------------------- a -4___1------------ <br /> ! 1� Permit No: -- -/1__--------� <br /> 7 <br /> (Complete in Triplicate) <br /> ----------------- --------------------------------------- k 'j I <br /> _______- This Permit Expires,1.Year From Date Issued ' Date Issued ___.______________ <br /> ' ? F <br /> i - i < - , W . ,. ;r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in corn pliance,with-County-Ord inonce-No.549'and-existing Rules and Regulations: <br /> - <br /> JOB ADDRESS/LOCATIO .1 p�------------------- ------------------------------- CENSUS TRACT ------------ ---. ....... <br /> Owner's Name ------ ' _ ' d �� <br /> one <br /> Address ------------------ --------------- <br /> 2-11 <br /> �__ <br /> %` t✓`' ''' ------ CirY " <br /> ------------------------- <br /> Contractor's Name ----- r - --- _-�'L��f`GG'-- 'License # ���- �i-------- Phone �_� � ------ <br /> Installation will serve: F� Residence-Apartment HouseF❑Commercial ❑Trailer Court <br /> a� Motel ❑ Other ----------------- --------- <br /> Number <br /> =_= r--------Number of living units:-----/__`."Number of bedrooms --- <br /> ------Oar'bc!ge�G 'nder -__ ------- of Size/ !. __ __ _________________ <br /> Water Supply: Public System and name -------------------------- - ------•... --------- --- --- --- % --4m-----------------Private ❑ <br /> Character of soil to a depth of 3 feet Sand❑ Silt E] Clay E] Peat E] Sandy Loam ❑ Clay Loam E] <br /> a Hardpan ❑ Aclobe)e Fill Material ----- ------ If yes,type _____________________ <br /> (Plot plan, showing size of lot, location of system- n 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 withih200 feet,) r <br /> �- <br /> PACKAGE TREATMENT [ ] SEPTIC. I ize---------- --X-- ---------------------- Liquid Depth -�------•-.----.-- <br /> 1 , <br /> Ca; acit / � ih"'-T e _ ____ _' __ Mate4ial_( .--- No. Compartments ----__ ---_---------% <br /> ..,. Distance to nearest: Well ----________________________ ____Fou-ndation --_�Q___-________ Prop. Line _ d.:'{._.--__--_ J <br /> LEACHING LINE �'[ ]�`' No. of Lines -------�_._________ Length of each line _______________________ Total Length ___________-___________._.__ <br /> Jr <br /> � to <br /> 0 D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------ <br /> Distance <br /> -------- ------------------Distance to nearest: Well ------ _________________ Foundation-- _.---= _________ Property Line --------------- <br /> SEEPAGE PIT [ ] Depth -------------------- .Diameter ---------------- Number ------------------------ Rock Filled Yes ❑ No <br /> ate <br /> r Table Depth ------------------------------------------ -Rock Size -------------------------------- S <br /> Dista _.... <br /> Distance <br /> to nearest: Well ------------------=---------------------Foundation -------------------- Prop. Line _...----• ............ <br /> ' REPAIR/ADDITION(Prey. Sanitation Permit#__________________________________---_-_____ Date _________________________________) <br /> u�ti <br /> SepticTank (Specify Requirements) -------- i---------- ------------------------ ------------------------------=----------------------------1•---------------------------- <br /> f <br /> Disposal Field (Specify Requirements)-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> t <br /> ------------------`--------------------------------------------------------------------------------------------------------------------------- <br /> -------------------- -------- -------------=--=--------------- - -------------------------------------------------------------- -------------------- --- ---------------------------------- <br /> - ------------- - <br /> '� (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 licbn- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance 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 laws of California." <br /> Signed --------------- - - Owner <br /> ----------------------------------- ------ <br /> By ---------- . -------------------------- ------ ------ Title -- ' -`---- ------- ----------------------------------------- <br /> (If of a than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACC ?TED 8Y ------------------ '- ------------------------------------------------------------------ DATE 3 3..�----- -------------------- <br /> BUILDING PERMIT ISSUED ---------- ------------ DATE ----------------------------------- <br /> ADDITIONALCOMMENTS ------------ -------------------- ---- -------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------'--------------------------------------"------------------------------ <br /> Final�lnspection by: ---- -- ----- Date .- --------------------------- <br /> "'o <br /> J - - <br /> / --� _ JOAQUIN LOCAL HEALTH DISTRICT <br />` <br /> NM f <br /> . 9 1-'6B Rev. 5 <br />