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A �I' <br /> FOR OFFICE USE: r/'6 <br /> APPLICATION FOR SANITATION PERMIT <br /> ------- -------w- ---- --------------------------------- <br /> (Compl�e in Triplicate) Permit No.. _7 Z-.g-l...�� <br /> � <br /> Date Issued ... =�-�- <br /> --------- -_----_.--__------------------- This Permit Expires 1 Year From Date Issued <br /> Al Application is hereby made to the San Joaquin Local He Ith District for a permit to co truct and installThw k herein <br /> k described. This application is made in complianc F� unty Ordinance N ,4.Q an� istingLRules angu tions: <br /> 1K7 II II11111���/� IUk <br /> JOB ADDRESS/LOCA71 �-l?�(-! --- °��- <br /> df <br /> --- <br /> Q9 S CENSUS TRACT <br /> f -- ------------------ phone <br /> Owner's Name - Q t I-_�P, <br /> --- --- ---- <br /> Address ------------------------- <br /> Owner's <br /> ---------------------- u� {i City � -a <br /> /� <br /> Contractor's Name ------- --' --------------------------------------License # Phone <br /> Installation will serve: 'i Residence Apartment House❑ Commercial �❑Trailer Court ;❑ <br /> Motel ❑Other ------�-- --- - --------------- <br /> Number of living units:.-"-......-- Number of bedrooms ---__...._Garbage Grinder - Lot Size -- <br /> Water Supply: Public System and name ------------------- - -------------------------------------------------------- <br /> ---------------------------------------------------- =---------------------------------- . <br /> Character of soil to a depth of 3 feet: Sand:E] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> �I Hardpan ❑ Adobe-❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot <br /> -------------------------_(Plot plan, showing size:of lot, location 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 /> PACKAGE TREATMENT f ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth ----------------------•--- <br /> CapacitY -------------------- Type -------------------- Material---------------------- No. Compartments ------------•......... <br /> Distance to nearest.. Well ------------------------------------Foundation ---------------------- Prop. Line --------------- ------ <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line____...-.- ------_____- Total Length ..-.---.-- -.-.------------ <br /> I -.� <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 <br /> i <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------.----------.---- <br /> A <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..-....-.--.-..-.--.---------.----} <br /> Septic Tank (Specify Requirements) -------------- - ' '--- -------------------------- - ------------------------------------------------------------------------- -- <br /> Dis osa field IS ecif R ireme s) ------ et ` 3�- ----- -b <br /> I � <br /> --------------------------S J - - ------------- -------------------------------------- --------------------- -------------------------- <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 in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> kas to beco subject to Workman>Compensation laws of California." <br /> Sign "al-Ie 2S - ------------- =----------- Owner <br /> BY - ------------------ Title ----- -- ----------------------- ------------------------- -- --------- <br /> (If other than owner) C <br /> ZEPARTMENT USE ONLY C <br /> - ����______` <br /> APPLICATION ACCEPTED BY ------- - -------------------------------------------------------- DATE .... - - `�� <br /> - --------------- <br /> BUILDING PERMIT ISSUED ------- -- - --- ------------- ---------------------------- -----------.DATE <br /> ADDITIONALCOMMENTS --------- - - -- ------------------------- ------------------------ -----------------------------------------I <br /> ---------------------------------------- -- ----- - --- -- -------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------ <br /> --------------------------------------------- - -- - - -------- --- ---------------- -------------' <br /> ----------------------------------------=-- - -------- ---- - --- - ---------------------- ---------------------- ------------------------------- p� --------Final Inspection by: ------- -- --------- - - --- ----- -- - %--------------------------------------------------------------Date --- <br /> OA <br /> fes. <br /> OAIJIN LOCAL HEALTH DISTRICT / <br /> E. H. 9 1268 Rev. M // <br />