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FOR OFFICE USE: <br /> �:�° APPLICATION FOR SANITATION PERMITo r5 <br /> 7rU-7°------------ -11 --------- Permit Na. -. <br /> i (Complete in Triplicate) <br /> _.________ This Permit Expires 1 Year From Date Issued 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 _______ -------AJ_ 'r <br /> RRf '' -----=---------------CENSUS TRACT 1 - ------- <br /> Owner's Name ------- --------- aG'. /---------- ----------;-------------------PhoneT�T'!3SV?-------- <br /> Address ----------- --------- � ---------- -- _-e_3 "�-----------------------------.--. City S�-------------- <br /> Contractor's Name ------__-_ _ _ ------------------------License #/4 ------ Phone%66_'" ® ... <br /> Installation will serve:_____ ---�Reii§:dence -Apartment,House❑ Commercial ❑Trailer Court ❑ <br /> J )"- , <br /> � <br /> Motel ❑.0ther ---------------------- _ <br /> Number of living units --Number'of-bedrooms ___rYGdrbage Gtirid -'-_ '_—Lot Size _ �. �� f)_________________ <br /> Water Supply: Public System and name __________________ <br /> - ---------------------------- - - ---------------------------Private ❑ <br /> Character of soil to a depth of 3 feet Sand'❑ Silt❑ Clay-❑� Peat❑—Sandy Loam C] Clay Loam E]t k`n <br /> Hardpan"❑ Adobe ` Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells,.,tibuildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: ` <br /> (No septic tank,or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT[ ] .SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth <br /> ' "� � --- <br /> . <br /> -------------------,_.--- <br /> Ca !citY �_ ! ------- --- Type ------------ ------- —aterial- - ----- -------No. Compartments ----------------------- <br /> Distance jto-nearest:. <br /> --------------- ----Distancejto-nearest:. Well''__- -------�------------------Foundation ---------------------- Prop. Line ----------:----------_� <br /> LEACHING LINE [ ] No. of-Lines _______________________ Length of each line---------------------------- Total Length ______-____.-____-_-___-____ <br /> 'D' Box A_------- Type Filter Material ---------------------Depth Filter Material ____________________________________________ <br /> Distance-to nearest:-Weld==_--:_----:—__--- Foundation --------'°__.__.___-___ Property Line ________________________ <br /> SEEPAGE PIT [ ] Depth ____ _________ Diameter __________- -___ Number _._.___._____- _!--____-___ Rock Filled Yes E] No 0 <br /> Water Table Depth -----------------------------------•----•-------Rock Size ------- -- -_------------•---- <br /> - <br /> Distance to_nearest: Well ---------------------1 <br /> -----------X.tFoundation -------------------- Prop. Line -------------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit _______________ --------------- Date_____._____________________.-._.) <br /> Septic Tank (Specify Requirements) ---- ------ -------------------------------------------------------------- -------------------------- x <br /> Disposal Field (Specify Require�ments) -------- ------------------ <br /> ------- _ <br /> ------ - <br /> --------`/0---- - <br /> ,„ - , <br /> - - - --- - -- ----------- - ---------------------------------- <br /> ------------ ----- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepares-this nppGa_iion�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." 4 <br /> Signed - ---- ;R Owner <br /> BY If other nrowner $ - Title -.------- ------- --- <br /> --- <br /> ( ) <br /> ARTMENT USE ONLY <br /> .APPLICATION ACCEPTED BY -- -- - --- ---------------------- -------------------------- DATE ----- -"'meq= � ..... <br /> BUILDING PERMIT ISSUED ---- - --- ------- - ------------------------------------------ --------------DATE ------------------------------- ---------- <br /> AD,DITIONAL COMMENTS ------- --- =---------- --- ---------- ------------------- <br /> --------------------------e <br /> ------ --------------------------------------------------------------------------------------------------------------------------------------- <br /> i <br /> -------------------------------- <br /> ------------- - --- ------ - ------- - --------•------------------------ ------------------------------------------------------------------------------------- <br /> Final'lnspection by: -----------Zt. - - ------------------------------•---------------------------------------..Date ars <br /> AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. ,'M <br />