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PFOB OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> /- - <br /> ---------- - - --- ------ (Complete in Triplicate) Permit No. _Z5 <br /> ...... ------------ Date Issued <br /> 4F This Permit Expires 1 Year From Date Issued <br /> ------------ <br /> --------------- ---------:---------------:---t <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 Count Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC ION ------- --------------------- -- ---------CENSUS Phone <br /> OAddress TRACT -------------- ----------- <br /> wner's Name --- -- -- - --------------------------- --­------------ -------------- <br /> 3 7 ---- ------------------------------------------ city ------------------------------------ <br /> or- d� -j/ <br /> Contractor's Name ------------------- -- - - ---------- ---------License # Phone ------------- <br /> -----_- <br /> Installation will serve: Residence)i(Apartment House�E] Commercial OTrailer Court :E1 <br /> Motel M Other -------------------------------------------- <br /> Number of living units:- /M1 <br /> of�Lrclrooms -c;;2------Garba-ge Grinder ------------ Lot Size ------------------------------ <br /> -4 Private E] <br /> Water Supply: Public System and name ---C <br /> Character of soil to a depthof3 feet: Sand Silt 0 Clay El ,Pecit❑ j Sandy Loom -E] Clay-Loam,[] <br /> .-!,.taw...- <br /> .Q.- ­_ — ' 7 <br /> Hardpan ❑ Adobe -Fill Material If ye s,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 [ I SEPTIC TANK'[ I Size------------------------------------- ;--------- Liquid Depth ---------------------.----- <br /> Capacity <br /> --------------------__Copacity -------------------- Type -------------------- Material---------------------- No. Compartments -------------------- <br /> Distance to nearest: Well ------------------------------------Foundation -----------------------.Prop. Line -------------- -------- <br /> --- ---------- <br /> LEACHING LINE No. of Lines ------------------------ Length of each line---------------_--------_--- <br /> Total Length --- <br /> 'D' Box ------------ Type Filter Material -----------------__Depth Filter Material --------------------------------------------- <br /> Distantb.to nearest.'Well ------------------------ Foundation -A---------------------- Property Line _.---------------------- <br /> 4-orlh, 49�i .2 1� <br /> SEEPAGE PIT Depth------------------- -, Qiamet'er--------------------Nurriber_--__..Number._ ------------ Rock Filled, yes rj No <br /> Size --- y <br /> Water Table Depth ---------------->1-1--- ------ ----------------Rock Si ----------------------------- <br /> I -i <br /> Distance to nearest-. Well ----------------------------- ----------Foundation! , ---- Prop. Line ------------- ......j <br /> 1. 1----i------------ <br /> RePAIR/ADUITION(Prev. Sanitation Permit# --------------------------- ------- ----- Date ----------� ----------------I <br /> Tank (Specify Requirements) --------- <br /> ----------------V--------j ------- --------------------------------------------------- <br /> - ------------------Disposal Field (Spe ------------------------------------------------------------- <br /> ---------------- <br /> - <br /> - <br /> rlx� 33 <br /> ----------------/----------------------- - --------------------- <br /> ------ ----- ---------- - - --------------------------------I------------------------------------- <br /> tp:Pgan/drequired addition on �everse side) <br /> I hereby certify that I have prepared .this.application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, cincl:Rules and Regulations of the San Joaquin Local Health District.-Home owner or licen- <br /> sed agents signature certifies the folic wing: <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 bec e su Gect to1W kma Compenscgti laws of California." <br /> ----------- <br /> Signed -- ----- - ---- - ---- ---- - ---- ---- <br /> -- Owner <br /> By --------------------------------- <br /> tle --------- -------------------------------------- ----------------------- <br /> - -- - - -- -------------- <br /> (if other than owner) - * <br /> FOR DEPARTMENT. USE ONLY <br /> APPLICATIONACCEPTED BY -------------------6;>---------- --------------------------------------------------------------- DATE ----- -- ------7 - - -------------- <br /> BUILDING PERMIT ISSUED --------- ------- - ---------------DATE---- ---------- <br /> ADDITIONAL COMMENTS -4 i. 4j---------------"---------'------------------------ ----------------- <br /> /116 - - ------------- <br /> --------------- ---------------------------------------------•------------------------------- ------------------------- ----------------------------------------------------------------- - ------- <br /> I r ------------------------- ---------- <br /> ----------------- ----------- ------------------------------- -(------------------------- --- -------------------------------------------------------------------- <br /> -----------------------------------------------------ve, ------ <br /> - - - -------------------------------------------------------------------------------------------------------------------------- <br /> Date --- - ----------- <br /> Final Inspection by. _------------- --- ----- - ---------------------------------------------- <br /> XSAN JOAQUIN ILOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M 4N. <br />