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FOR OFFICE USE: <br /> --------------- - <br /> `�-APPLICATION FOR SANITATION PERMIT //z4 <br /> - ---- Permit No. --/- -----(Complete - <br /> in Triplicate) <br /> ..................................................... This Permit Expires 1 Year From Date Issued <br /> Date Issued <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 /> JOB ADDRESS/LOCATION _____ . ��_ ��___ __. / ___ -1, - � -----..CENSUS TRACT __.__________.._.__._.__ <br /> Owner's Name +`/-�hC? CQj Phone <br /> `� ----•----- <br /> Address ---- - / 1,c3� X�---/ -- -�� Y v '------------------------------------- <br /> {�- -------------------•--------. Cit -- - <br /> Contractor's Name ------------------�Q�G� ____.-- <br /> ----- --------------------------------License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence partment 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 -----------•------------------------------ ---------------------------------------------------------------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 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ____.-__---__-._-_--_-___ %Y <br /> 0 <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- V/ <br /> Distance to nearest: Well ____________________________________Foundation --------- ------------ Prop. Line ____________-_____._-- Q <br /> LEACHING LINE [ ] No. of Lines ------..---------------- Length of each line_________________________ Total Length .-.-_-____-_ � <br /> --------------- <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 ❑��S <br /> Water Table Depth ------------------------------------ v-'---Rock Size ----------------------------_ V <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) s <br /> Septic Tank (Specify Requirements) --------------- -j ��--------------------------- - ---------------­---------- <br /> Disposal Field (Specify Requirements) _._._____ _ __��(_--- ---------Z�...... <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 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 /> .� BY - ---------------- Title - - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ - ------ --------------- ---------- ----------- DATE ._/�_—. ./.-7 ....... ------ <br /> ---- ------------ <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------ ---------DATE -..---------- ----------------------- <br /> ADDITIONALCOMMENTS -----------------------------------•-----•----•-•-------------------------------------- ------------------------------------------•----------- --------------- <br /> -------------------------------------------- ----------------•-----------•------------------------------------------------------------•-------------•---•------------------------------------------------ <br /> ----------------------------------------------------------------------------------------------••------------------•---------------------------••---------------------------------------------------------- <br /> ,+ ... ------ --------------------=------- <br /> Final Inspection by: ------ ------ C �--- '--- ------------- ----------- --------- ----------_-------------------Date -�21---------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C u n i Ito D.... CAA <br />