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FOR OFFICE USE: <br /> ,_......._.. APPLICATION FOR SANITATION PERMIT <br /> ........................................... Permit No. ..�.�...:. 3T <br /> (Complete In Triplicate) •"'•" <br /> r .._ <br /> This Permltfxp(res 1 Year From Dohs Issued Date <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. 54.9^and existing Rules and Regulations: <br /> JOB ADDR155/LOCATt -5..: ...... .... ... .... � ... ......Ex...�.>......CENSUS TRACT .......................... <br /> Owner's Name ..,.. 'w^�S..l ....... .. ....fJ. . ... ....�..4•.0. ............. ......Phone ......... .......................... <br /> Address . . S..A_. .. =.. ....................... ......................................City ...................................... ............................I........ <br /> . <br /> Contractor's Name .............................................. ... ....................................License* .............. ......... Phone ....... ................... <br /> Installation will serve: Residence Apartment HouseO Commercial QTraller Court O <br /> Motet ❑ Other ....... .................................... <br /> Number of living unitss...�----- Number of bedrooms ..h...Garbage Grinder ............ Lot Size .../ <br /> Water Supplyr Public System and name ..................................._...........:_.......».................................... ............Private V/. <br /> Character of soil to o depth of 3 feet: Sand 1b Silt❑ Clay O Peat❑ Sandy Loam lay Loam ❑ <br /> Hardpan C] Adobe ❑ Fill Mcterial ... ........ 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( ] Size................................................ Liquid Depth .......................... , <br /> Capacity ._1,2.4_aype ...................: Material.............:, ..... No. Compartments .......:............... 1 <br /> Distance to nearest: Well ....................................Foundation:..................... Prop. Line ...................... <br /> LEACHING LINE [ J No. of lines . ._. .--...... .. Length. of each ............... Total Length .. ...?..tS ..... <br /> 'D' Box ...... ..... Type Filter Material ....................Depth Filter Material ............................................ <br /> k ��y <br /> Distance to nearest: Well . ...Gr'..�.... Foundation!........-..��._Property-.Line:�:P` <br /> SEEPAGE PIT [ ) Deptn ..._ ..... Diameter ............... Number .................. ......... Rock Filled Yes ❑ No (] <br /> Water Table Depth ._._......:...............................:..Rock Size ........................------- E <br /> Distance to nearest: Well ........................................Foundation ..................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ....::...................................... Date ......:...........................) <br /> Septic Tank {Specify Requirements) ............... <br /> .................................................................................:........................................... <br /> Disposal Field (Specify Requirements) ..._........ ............. :....................--•---..... ...... ....� ...................... <br /> ........................J w <br /> ....................d......................................................................:............ ----- <br /> .................----..........................I......:..._...._........._........_..........-----------....----.......................-•`....................................................... <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,Distdct. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance 914he work for which this permit is issued, I shall not employ any person In such manner <br /> as to beta •ett to Wor 's o peolsolion laws of California." <br /> Signed . _........ � -_�1.� ............ Owner <br /> .... . ....................... <br /> ..._. <br /> By ......... .. •--•................................................ ........................... <br /> lif other than owner) <br /> FOR DEPARTMEN E Y <br /> APPLICATION ACCEPTED BY...................................... .... ...... .. ---.DATE <br /> . .......,...... <br /> BUILDING PERMIT ISSUED ....:`. ..:.... ................ ..:... .......... .................. ... .... . ...............DATE ........................................... <br /> ADDITIONALCOMMENTS ......................... ................. ._... ....... -`-....... . .....................................................,......-......_............ <br /> :-•--. ................... . ........................_............................. - ---..._.................-_.....------------•--..........-....._.... ....... <br /> ............................... ...............................'...............................--............................... .. ................................................ <br /> Final Inspection by: ...--....................."------........._.. ......................................... ..............Date ....... .-. .......... <br /> t. <br /> EH 13 2!t 1-68 Rev, 5}4 SAN JOAQUIN. LOCAL HEALTH/01 RICT 8/711M <br />