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.S <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------- (Com-lete in Tri <br /> - pli-cote) �..-w. <br /> p <br /> --------------------------------------- r � Date Issued <br /> --_---_-- `�"-`- This Permit,Expires 1 Year From Date'Issued"1� �... <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ------------------------- 'r-CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOC TION0-.-- -l �,1 f <br /> Owners Name - a- -- __-- � ---- <br /> fT' ` ' L ---------------- <br /> - Phone -5---------- <br /> Z 176 L0 7 <br /> Address -.� .OlE7f` v -.' -------------------------------------------- Cit J�v _��+ / ✓tr`is <br /> Y <br /> t ------.License # ------------------------ Phone_ ------------------------------ <br /> Contractor's NameG1�i!/E2-1----- ------------------------------------- - <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑ Other Ada / <br /> Number of living units----/------ Number of bedrooms_2------ Grinder -' _-.- Lot Size 3/ ,qC,� S-------_ <br /> i.\ <br /> Water Supply: Public System andname ------------------------[ --------------------------------------------- ------Private ) <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt]] Clay ❑ Peat E] Sandy Loam [] Clay Loam M <br /> � Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes,type ----------------------- ---- <br /> (Plot plan, showing size of lot, locatiot5—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,) r \ <br /> I ------. Liquid Depth ----------.- <br /> PACKAGE TREATMENT [ ] , ( ]. <br /> SEPTIC TANK Size--------�--S--x--�----------- <br /> --- -----•-w - <br /> Capacity - ;� ------- Type --------- ---------- Material- / No. Compartments -----------------=---- <br /> r <br /> i r <br /> Foundation -----------.Prop. Line .----Y1.5-6 � <br /> Distance to nearest: Well ------------ -- ' <br /> r -- r t <br /> LEACHING LINE [ ] No. of Lines -------- Length of each line.---:-7�--------------- Total Length -_- .-----_:----_. ._---_-._ <br /> i$ <br /> .Box - ---------- Type Filter Material ------ ------Depth Filter Ma#erial ____---__�--------------------------------- <br /> 'D' ......... .. <br /> r <br /> i Distance to nearest: Well -� ---_------ Foundation _ ------------ iProperty Line <br /> SEEPAGE PIT Depth - Diameter -7-------------- Number -------I--------------------- Rock Filled yes ❑ No ❑ <br /> Water Table Depth Rock Size -------------------------------- <br /> ,.t <br /> Distance to nearest: Well ---------------------------------- ---- Foundation -----:-------------- Prop. Line -•---.....----••----.. <br /> l~ I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- Date ----__-_----_----:---------------? <br /> L I <br /> k Septic Tank {Specify Requirements) ------------------------ --------------------------- <br /> __1.--------------- ----- <br /> I Disposal Field (Specify Requirements) <br /> -------------------------------------------------------------------------------------------------------------- <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 /> 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 ' the performance o the work for which this permit is issued, I shall not employ any person in such manner <br /> as to beco ct.t W a Co pens i.on s of California." <br /> Signed ------------------ Owner <br /> Title --- <br /> _ I __ - ------------------------- ---- <br /> BY -------------- -------- <br /> (If other than owner) <br /> I FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B 5 ------------------ --------------------------------------------, DATE. - �? <br /> lo <br /> ------------- <br /> BUILDING PERMIT ISSUED -- ---------- -- ---- DATE --- ----•--- <br /> . <br /> ADDITIONAL COMMENTS ---------------------------- - -------------- --------------------- <br /> ---------------------------------------------------- '------------------------------------------- ----------------------------------- <br /> t <br /> -.------------------------------------------------- ------- ------ ------------------------- <br /> -------- <br /> ----------------------- <br /> ---------------------------------- --- ------ - -- <br /> ------------------- - ------------------------ ------------------- <br /> ' Final Inspection b -----Date ....--- c <br /> - ------- - --- -- - - -- - <br /> l SAN OAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />