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FOR OFFICE USE: 6af Iq z—d q <br /> a APPLICATION FOR SANITATION PERMIT <br /> - � <br /> ------------------------------------------------ Permit No: <br /> (Complete in Triplicate) PP <br /> -------------------------------------------- <br /> r <br /> ___._.-___.__ I jhis Permit Expires 1 Year From Date Issued Date Issued _F-_ � 8' <br /> ------------------------- - <br /> .F <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein I <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: i <br /> K r <br /> JOB ADDRESS/LOCATION . _ ,/� 2- °i <br /> �� - � � // /` -`r'�'---� �--,_��� SUS TRACT -------------------------- <br /> Owner's <br /> ---------- ------------- ' <br /> Owner's Namef ----------------------- ------- ---------------------------- ------------------Phone '_cG ..._.. <br /> Address --- -- Cit Z�,-'�'. --------- <br /> Z <br /> Contractor's,Name - -- '-� ----- - - - A02-A---------- # --- - :-------------- Phone -------------------------..... <br /> Installation will serve: Residence A- artment House❑ Commercial ❑Trailer Court [] <br /> Motel ❑ Other <br /> Number of living units:------_---_ Number of bedrooms ------------Garbage Grinder ------------ Lot Size e ��______---- <br /> Water Supply: Public System and name ------------------------- ------•- •------ ----------------- ..-------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sdnd'❑ Silt(] Clay ❑ Peat❑ Sandy Loam ,E] Clay Loam 0 <br /> Hardpan Adobe ❑ Fill Material ------------ If yes, type -----____-__-------------- T i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must he–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 /> U`l , <br /> Capacity --A---------------- Type -------------------- Material-------- ------------- No. Compartments -------------• -- <br /> Distance to+ nearest: Well ---_--_----------------------------Foundation ---------------------- Prop. Line ---_-_-_-----_-----_- <br /> LEACHING LINE [ ] No. of Line- ------------------------ Length of each line---------------------------- Total Length ----------- _------------- <br /> 'D' Box --{i-' --- Type Filter Material R--------------------Depth Filter Material --------------------.---------------------_ ` r <br /> Distance to,nearest: Well ------------------------ Foundation ------------------------ Property Line, ---_--_-.._-_-----.__.-- N ' <br /> SEEPAGE PIT [ ] Depth ------- ------------ Diameter -------- ------- Number -------------- ------------- Rock Filled Yes ❑ No 0 y� <br /> Water Table Depth ------------------------------------------------Rock Size ------- ------------------------ <br /> Distance to nearest: Well -----'----------------------------------Foundation -------------------- Prop. Line ---------------_---- <br /> REPAIR./ADDITION(Prev. Sanitation Permit# ---__----- -- -c-------------------- Date ---------------------------------- <br /> Septic Tank (Specify Requirementsr) -------- ---------------- ------------------------------------------------------------------------ -- --------- ----- <br /> Disposal Field (Specifyy Requirements) __! ______�_______ J� �=- � <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------- <br /> ------------------------ <br /> ---------------------------------------------------------------- - -- ------------ --------------------------------------------------- <br /> - - --------- <br /> " (Draw existing and required Addition on reverse sided <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 Regulotions.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 beco u"%ct to or �' aticin laws of California." <br /> Signed �- Owner <br /> By --------------------------- -------------------- ------ Title --------- ----- <br /> (if other than owner) n{ <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> . -- ----------------- ----- ----------------------------------- <br /> DATE -�---�a�--- ---�- -U��-------- <br /> BUILDINGPERMIT ISSUED .---- -----------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS <br /> --------------------------------------------------------------------------------------------- -------------------------------------------- <br /> ------------------ --- ---------------------------------------r-------------------------------------------------------------------------------- ----------------------------y--�--- <br /> ------------------------ <br /> ------------------------------- ----- <br /> -------------------------- - - -- - ----------- ------ -------- - - --Final Inspection b --------------------------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />