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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------/0;w------------- � Permit Na> <br /> � J. (Complete in Triplicate) ' <br /> ----------------------------------------- ---------- �m, . R. `A -.„-,-- <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/LOCATI - r------------------------CENSUS TRACT -------------------------- <br /> -------------- - -- - ----- - <br /> h <br /> Owner's Name --------- ------- <br /> Address ---------------------------- - ----- City ----------------------------------------------------------•----- --•-- <br /> Contractor's Name ____________ __f � <br /> ` <br /> F - �°-- �,.-_5=0'yc --------' ----- <br /> ------=--------License #f���L---------- Phone 7�a����_�_� , <br /> Installation will serve: °IResidence�Apartment House❑ Commercial :❑Trailer Court ;❑ f <br /> Motel ❑'Other ¢ r <br /> Number of living units:-----t---_ Number of�b_edrrooms ____ -___Garbage�Grinder __�F ______ Lot Size -.__ .--X --ZQ______________ <br /> Water Supply: Pbc-System and name ?ti 'C �'t - - Private ❑ <br /> x - , <br /> Character of soil to a depth-of-3-feet:.- Sia"nd'Q-�LSilt.❑----Clay-❑ Peat E] - Sandy Loam fl-- Clay Loam (] <br /> Fav <br /> Hardpan❑ Adober(X Fill Material ----- If yes, type _________________________ - <br /> (Plot plan, showing size of lot, 'locati°on of system in relation to wellsF bdi dings, etc. must be placed on reverse side.) �+ <br /> NEW INSTALLATION: (No septi I'll, <br /> tank or seepage pit permitted if public sewer is available within 200 feet,) ' <br /> PACKAGE TREATMENT TANK'[ ] Siie------------------------------------------------ Liquid Depth -----------------------_--, <br /> �+ "�' <br /> 4 ! , Type Matenal � No. Compartments ------••-•-•- -------- <br /> Capacity <br /> Distance; o nearest: Well ------- --------- ---- ---------------------- Prop. Line ----------,-•--------- <br /> LEACHING CINE [ l.t No. of Lines _--__ ___- --_.,Length .of. each line._______c__________;_ Total Length ----:--'___ _______________ <br /> r <br /> 'D' Box ----- = Type Filter Material -------------'------Depth Filter `Material -------------------------------------------- <br /> T <br /> -------------------.----:---- <br /> Distance to (nearest: Well _______________________ Foundation .____.___--_____ ---- Property Line, ------------------- <br /> SEEPAGE PIT [ Depth _:.__.__�___________ Diameter --------------- Number _____.______________ ___ Rock Filled Yes EJNo " <br /> Water Table"Depth----- -------------------•---------------- Rock Size -----------`------- -------- <br /> Distance-to nearest: We ----- -:--�=Foundation ------- ------------ Prop. Litre ----------------___.-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit _ __ Date ___----------_.___ <br /> -------------- <br /> Septic Tank (Specify Requirements` _ ---------------------------------------------------------------------------•-- -------------------- <br /> Disposal Field (S fy Re irements) ------------------------------ ------ -------------- <br /> I ------------------------------ <br /> ----- - ;`T <br /> -- - -- - ------------------------- <br /> (pro existing. nd 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, ,and!RulcsVancl Regulations of the San Joaquin Local Health District. Home owner or Rcen- <br /> sed agents signature certifies the following: " <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed <br /> Owner <br /> e -- ------------------------------------------------ <br /> By ------ - -� - - --- ------------------ -Tit <br /> If✓o ' than owner) I _t <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B,- ----'t----- -----'-----------------------------`-------------- rbATE ----- -- -------- <br /> -------- <br /> ----- --- -._±. __DATE ----------------- <br /> BUILDING PERMIT ISSUE __ _-- ':__-- ! <br /> ADDITIONAL COMMENTS --------------- <br /> - - ---------------------- - -----------------------• <br /> �� <br /> A <br /> --------------- <br /> -------- -- -- - <br /> �F• <br /> ______________________________________________________!------- _ _ _ _ _ _ ___________ <br /> Rr Q-q--__ _ r___ _ _ _________________________________ <br /> Final Inspection by: -------------------- ---------------------------- Dote _ �(�Oj -------------------------- <br /> I SA6'JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />