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FOR OFFICE.USE: APPLICATION FOR SANITATION PERMIT Permit Na.7O.r <br /> + --------------------- ------------------- ----------- <br /> (Complete in Triplicate) <br /> This permit Expires 1 Year From Date Issued <br /> Date Issued <br /> ----------------------------------------- <br /> ---------------- <br /> Application is hereby.made to the San Joaquin Local Health District for a per 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 /> �� __ _� I --_.lel. ---._ ' --CENSUS TRACT _5--�F------------- <br /> JOB ADDRESS/LOCATION CMZ <br /> Owner's Name - - � - = 1 --Ami ----------------------------=- -------Phone ------------------------------------ <br /> ry f <br /> Address _ { ---- ------------------------------- City ------ ----------- -------Coni 1`�r4i Name --�i�-- -- .- -`�7 1--C -T 1u-tf-Of__797 .License # ------------------------- Phone <br /> f Installation will serve: Residence]KApartment House-E] Commercial :❑Trailer Court ;❑ <br /> t <br /> Motel ❑ Other ------- ------------------------ ----------- <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size ____________________________________________ <br /> Water Supply: Public System and name -----------------------------------------------•--------------------------------------------------------------.Private ❑ <br /> I Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Clay ] Peat❑ Sandy Loam -❑ Clay Loam:❑ <br /> -.9-Fpm -,&Hardpan E:]—A-dobo-❑-Fill Material,-::='—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 /> p seepage pit permitted if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: (No septic tank or <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------•----- - Liquid Depth ---------------------.----- v� <br /> Type -------------------- Material---------------------- No. Compartments ---------_. -. <br /> Capacity -------------- Yp - ••-----• <br /> Distance to nearest: Well ________________________________ p• <br /> __._Foundation --------'------------- Pro Line ................_-_--- <br /> LEACHING LINE [F] No. of Lines ------------------------ Length of each line----- ---------------------- Total Length ------------ ----­--------_ n <br /> ' 'D' Box ------------ Type Filter Material ------------ --r_r-___DeiJth Filter Material ----------.---------•-.--------..-.-•--•---- • �1 <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line -------------_------ <br /> SEEPAGE <br /> _._________._ --.__SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ t <br /> Water Table Depth --------------------------------------------•_..Rock Size <br /> r Distance to nearest: Well -----------------------------------------Foundation ------------- Prop. Line -_-----------_------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} <br /> Septic Tank (Specify Requirements) = -------- --• --- -•--------- --------------------•---------------------------- <br /> Disposal Field (Specify Requirements) _ ------------------------------------- <br /> -------------------- • sE ` rt A ---- --y--------------- - -------------------------- --•--------- <br /> t ---------------- ------------------------------------- ------------------------------------------------------------------------------------------------------------------------ ---------------- <br /> ,, (.Draw-existing=and-required-addition-on-reverse-side) F <br /> 1 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 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." <br /> Signed ------- -- -------------------------------------------------------------------------------------- Owner <br /> -- ---------------------------------------------------- Title ---av °-------------------- --------------------------= <br /> (If oth r thowner} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ---------------------------------------- ---------------------------------------------------- DATE sS-'. %`7 --------- <br /> IBUILDING PERMIT ISSUED ---------------------------------- ------------------------------------------------------------------------DATE ------------- ------•--------------------•- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------- ----------•---------------- <br /> -- --------------------------------------------------- ---------------------------------------------------------- -------------------------------- <br /> ----------------------------------------------- ------------------------- ------------- ----------- ----- <br /> i ,�� <br /> Final Inspection by: ! ' ,.,t .� -------------------------------------------------------------- - ------Date . ----- --- ------------------ ---- <br /> SANAOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'G8 Rev. 5M <br />