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FOR OFFICE USE: � <br /> '"�� APPLICATION FOR SANITATION PERMIT <br /> d Permit No. � ._. <br /> (Complete in Triplicate) <br /> ----------------------------------------------------------- <br /> Date Issued --- <br /> I This Permit Expires 1 Year From Date Issued <br /> -------------------------------- <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 Rut s and Re lations: <br /> JOB ADDRESS/LOCATIONi <br /> F - ` AC7---�"°�------ PhoneOwner's Name ,1 <br /> 1 <br /> l __ Ci # <br /> Address h 'tr>y ty - i <br /> i <br /> Contractor's Name _ __r---------------------------------------------------- -----License # ---------:-------------- Phone ------------ ----------------- <br /> Installation will serve: Residence* Apartment House-E] Commercial[-Trailer Court ❑ <br /> 11 <br /> Mote! ❑ Other -------------------------------------------- <br /> Number <br /> ------- ---------------------------------Number of living units:____/______ Number of bedrooms ________Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> Water <br /> ---1_---- -___l----------------•----- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------- ----------------Private ❑ <br /> u <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, ii;loc ition of system in relation to wells, buildings, etc. must be placed on reverse side.) i <br /> ,I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public se r is available within 200 feet,) <br /> .--- -� cr,_ __ Liquid Depth <br /> ----- ` <br /> PACKAGE TREATMENT [ I SEPTIC TANK T Size__-___f ,,- '� �_�-__ �_� q p <br /> II <br /> Capacit ----- Typ _--_a.--------- Materiale�-_cc_'----- .No. Compartments -2"---------- <br /> DistanceLi ----- <br /> a <br /> to nearest: Wel[ -- --fl-------------------------Foundation .../0----------- Prop. Line __r_---:-------- <br /> LEACHING LINE No. of nes _.- _____________ Length of each line----__/_-_k_1_..______ Tota[ Length ____ - <br /> --------- <br /> 'E <br /> --- Type Filter Material -------Depth Filter Material _-!_ ---------------------------•-_---- <br /> Distan e <br /> to nearest: Well ____3� d _________ Foundation ----YL.0/---------- Property Line. ___tr................. <br /> y-- Number ------�---- -?------ Rock Filled Yes 0T <br /> SEEPAGE PIT � f Depth �'�'_________ __- Diameter -� __.__ /� No <br /> Water able Depth --- -----------------•----------- ..Rock Size -- -=------=-- ------------- <br /> Distance:lto nearest: Well ---'-�_�___-__- ----------------Foundation ____/-6_________ Prop. Line ----J __-_____-.-- <br /> .i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> SepticTank (Specify Requirements) ------------------- ---------------------------------------------------------------------------------------------­-------------------------•- <br /> 4 <br /> DisposalField (Specify RequiIrements) -----------"------------------------------------------------------------------------------------------------------------------------- <br /> i <br /> I ------------------------------------------------------------------------------------------------------------------------------------------------- ------------------•----- <br /> --------------------------------- <br /> - <br /> I --------------- - <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,'Cand Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the'rfollowing: <br /> I, "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 /> kas to become object to Workman' Compensation laws of California." <br /> Signed ----------- ------------------ Owner <br /> i U <br /> -------------------------- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------ ------ ----------------------------------------------- DATE _6'/f`_7 O--•------------------- <br /> BUILDING PERMIT ISSUED ------- DATE - ----- ------ ---- <br /> I . ADDITIONAL COMMENTS -- c'¢c,-- - ---`-'-- -- bre---G=-f��=-------`-----�i -0h-1.-.--2zc�`--- --- -- <br /> --------------------------------------------------------------------- -••------- <br /> ------- -- - -------------------------------------------------- <br /> i ----------------------------------------------------------- <br /> it <br /> ------------------------------------------- <br /> -------------------------------------- <br /> I ---- <br /> Date <br /> Final Inspection by: - - - - ------ -- ---------------------------------�----------------------- - <br /> - --------- <br /> .M _ <br /> r . �i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M I� <br />