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R <br /> FOR OFFICE USE: <br /> APICATIO' i FOR SANITATION PERMIT\ /4 z <br /> - ----. ----------- - --- -- Permit No. - = <br /> (Complete in Triplicate) . <br /> -- ---------------•-- ---•--------� ,,// �_ 7q <br /> i This Permit Expires 1 Year From Date Issued Date Issued <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> ascribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> J08 ADDRESS/LOCA T N ._ -. -------- ` /�c ..--L�c.r�]'n( ,'...CENSUS TRACT ---------- --------------- <br /> 4 owner's Name -* --- Phone <br /> ?ddress .. n C '' b-.. -. sa ---. City -- ---- <br /> _Contractor's Name ...-...--... ------------------------ --•--------------------------------- ------License # ------- ---- --- =---- one ...... ---------- -- <br /> nstallation will serve: Residence ❑ Apartment House❑ Commercial �ailer Court 0 <br /> Motel ❑ Other ......... -------------- ------------- <br /> F )umber of living units:.........:.. Number of bedrooms -----.------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 ❑ U <br /> Hardpan I] Adobe ❑ Fill Material ............ If yes, type ----- --------- ------ <br />" (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> FEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available.within 200 fest,] <br /> PACKAGE TREATMENT [ 7 SEPTIC TANK'[ ] Size-----------------------------.------------------ Liquid Depth -------------------------- <br /> Capacity <br /> ---.-------- --.Capacity -------------------- Type -------------- ..-- Material_................... No. Compartments ---------=--------•--- <br /> w. Distance to nearest: Well -- ---------------------------------Foundation ------------------ --- Prop. line ---------- -------- <br /> LEACHING LINE [ ] No, of Lines -------------- ------ Length of each line------------................ Total Length G <br /> 'D' Box .---........ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ____- ------ ---- Property Line (6 <br />! EEPAGE PIT [ ] Depth -------- ---- - --- Diameter -----. ---.--.-- Number --..---..-.-.---...-. ...... Rock Filled Yes ❑ No ❑ <br /> ' Water Table Depth - ------- - ---------------------------------Rock Size ........ ----------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation .------------------- Prop. Line ----------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------- . <br /> I Septic Tank (Specify Requirements] .- - -- ----------------- ------------------- --�---:- - <br /> I Disposal Field,i(Specify Requirements) ---.--x- G ---.--1 -� ---- ----- ` <br /> f . <br /> ------------------------ ------ --- ---- --------------------------------- ----------- ---•----- -------------------- ------ -- --- - ----------------------------- <br /> (Draw existing and required addition on reverse side) <br /> Fhereby 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 liven- <br /> ' ed agents signature certifies the following: <br /> ,I certify that in the performalice of the work for which this permit is issued, I shall not employ any person in such manner <br /> `ua to beco ub;eo rlrmon's Comp nsation laws of California." <br /> r <br /> 'gned •( . r `- ------ Owner <br /> Y ---- --- - -- -------- ---- --------- • Title .......... .... <br /> (If other than owner) <br /> _ FOR DEPARTMENT USE ONLY <br /> ( I�kPPLICATION ACCEPTED BY ...-ate---:- . <br /> ----------- ---------- -------- - - DATE . - --- -------- <br /> BUILDING PERMIT ISSUED ------------------------ ------------------------- --------------- ------- - -DATE ----- -------- ------------- <br /> DDITIONALCOMMENTS --------------•-------•---- ---------------------------------•--------- --- ........... -------------- ...... <br /> - --------------------------------- -------------•------ --......---------.---.--------...------------- ........................ <br /> I ----------------- ---------- ------- ----- ----- -----------------:--- - ---- --- ­..._.. -......- -----------------------------------..-..---•------ <br /> inal Inspection by: --- ----- __ _ ; : , ------- -- Date ..........................I--`- . . _. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _�[l <br /> DRi <br /> r u 0 t-'/,A va,. rnh <br />