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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.,Gi----�- <br /> -70--------------�r -_� (Complete in Triplicate) 77 <br /> --------I---------------- - ----- � r � Date Issued ./ <br /> This Permit Expires 1 Year From 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 Ordina a No. 549 and existing Rulesand Regulations: <br /> -----------CENSUS TRACT --------------_--------- <br /> JOB ADDRESS/LOCATION -- d-Q_____-/1�(!-- / <br /> Owner's Name <br /> -- - ---- <br /> ------------ - ---- - - <br /> ---------Phone 02--363--a- <br /> ----Address CifiY ---------------------------------------•--------- ► <br /> - ------------=----------- <br /> - I/------ Phone ``�` .�7 <br /> Contractor's Name ______ ______ <br /> Uwj ---------.License # f -0 <br /> Installation will serve: Residence E]Apartment Nouse°❑ Commercial ❑Trailer Court C] <br /> Motel ❑ Other ____ --------------- <br /> Number of living units:--- _ Number of bedrooms ----____.Garbage Grinder ---------- Lot Size ---___----- ---- ------ ----------• <br /> Water Supply: Public System and name -------------------------------------------------------------- ------------------------------------------ <br /> -------------------- - -- ------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay .❑ Peat❑ Sandy Loom ,E] Clay Loam:❑ <br /> —Fill.Material _ _-...If. es,-t. a ---------------------------- <br /> Hardpan_[]w YAdobe_K Y YP <br /> (Plot,plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> s fit' { <br /> NEW,INSTALLATION (No septic tank'or seepage pit per if public sewer is available within 200 feet,) % <br /> r.--.-.-^•.__ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--------------------- - - Liquid Depth _.__------------.•-------- <br /> ,-- <br /> —Capacity---------------------- TYPe ----- _-�- Material---------- --- ----- No. Compartments -- <br /> Com P � <br /> --,•----•----- --------------- <br /> Distance to nearest:;.Well ---------------------- ___<�._:._.Eoundation--------------------- <br /> Prop. Line <br /> f LEACHING LINE [ ] No, of Lines --------- Len-- g � , <br /> -_ Length of each line------------------------{-�-A Tota! Length, ------------------------------ <br /> f l _De Depth Filter Material <br /> D' Box ---- �,'-- TYPe Filter Material ---- -------------------- ------------------ <br /> ----- Property Line ---------•----- ----- <br /> •Distance to nearest: Well r_____ _____________-�-- Foundation P rtll <br /> I , <br /> SEEPAGE PIT [ 3 Depth 'DDiameter ---------------- Number -_---- �:----------- ----- Rock Filled Yes ❑ No �❑ <br /> - -- ----- <br /> I Wates Table <br /> Depth- ---- -------------------------`-----------------Rock Size <br /> -nearest; l <br /> -�- -"._-- -------------------------------- <br /> Foundation <br /> ---- ---f---------------------- <br /> Foundation- _, --- Prop. <br /> Line -----------_------ <br /> G — " Distance'to Well---- a # _Pv (Sanitation Permit# , <br /> REPAIR/ADDITION.(_ 1 <br /> ` ents)'+ -- -- ------------- <br /> ------------------------------------- <br /> - <br /> ------------- ----------------------- #. --------------------- .--------------------------- <br /> ' SepticTank (Specify RequiremF.". <br /> -------------------------•----------- <br /> 5t ' -- ------------------- <br /> Disposal <br /> * _ _ <br /> D'sposal Field (Specify Requirements) ----- - ------------ --------------------------—________.____________-__ <br /> 'r <br /> V <br /> -" __._ <br /> ------------------------------------------------------ <br /> ' '(Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared(this applicationrand that the work will be,"done in accordance with San Joaquin <br /> County Ord riances;)State,Laws„ .andM'Rules.and`Regulations of. the.”San..Ioaquin_Local,.tiealth�istroct. home owner or licen- <br /> sed agents signature certifies 04-followiitg: <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 /> r as to become subject to Workman's CompeAsiation laws ofSalifornia." <br /> Signed ------------------------- ------- ------------------------------------------ Owner <br /> --------------- <br /> _� ------------------"- ---------------------------- <br /> BY ---------- --(Jti --------- ------ ----- ------------------- Title <br /> (If o than owner) <br /> PARTMENT USE ONLY <br /> i APPLICATION ACCEPTED BY - ----------------------------------------------- ------ DATE — d <br /> ' BUILDING PERMIT ISSUED -------- - ---=- DATE ------------------------------------------- <br /> ADDITIONAL COM T --- <br /> -- -- ----- ---------- <br /> ----- <br /> - <br /> __ -�__________ _ _ ____. -- ---- --- <br /> _ ____-_____________________-___ <br /> .___"_______________________________ _ ----- ___ __ _ _ _____.-__________________________________._____---------------------------_____.____________"__________________________-_____------- <br /> Final Inspection by: - ---�---- ---------------------------------------------------- ---------------- Date _.. "' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Cx� <br /> E. H. 9 1-'68 Rev. 5M <br />