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f - <br /> i <br /> r FOR OFFICE USE- <br /> / APPLICATION FOR SANITATION PERMIT permit No: .._ <br /> ----- <br /> - "" =Complete in Triplicate} <br /> ------------- 7 <br /> This Permit Expires ] Year From Date <br /> Date Issued --.-_____._--.-_ _ <br /> --- _ -------------------------------- Issued <br /> Application is hereby made to the Son 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`LOCATION -----Q� -------------------- ----------------,---------------- -CENSUS TRACT --------------- ---------- <br /> Owner's Name----��� � ------------------------- --'---------------`------------------- Phone <br /> - - s <br /> Address _11�1----------4 j7 ------------------------------ti City Y--------------------- -------------------- <br /> 7 <br /> Contractor's Name _l� L� - ------------------------- License # ZTW -- Phone .--- <br /> Installation will serve: Residence jaApartment House❑ Commercial ❑Trailer Court '❑ <br /> Mote! ❑ Other --------------------------- ---------------- <br /> Number <br /> ----------- --Number of living units:__'/_------Number of`bedrooms "Garbage 0-�-1 <br /> Grinder , �-__ Lot Size !-=3 2Q-1----------- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------- -----------------Private ❑ <br /> Character of soil to a depth of 3 feet: ; Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .0 <br /> t <br /> Hardpan ❑ Adobe Z Fill Material ----- -_____ If yes, type ----------------------------- <br /> (Plot <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 t nk or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------- ---- Liquid Depth ------------.--------.----- <br /> i l---------- - ------ No. Compartments -----------_Ca <br /> Capacity ---- Type ---------- -- Materia <br /> X' <br /> Distance to nearest: Well --------------------------•-------•-Foundation ---------------------- Prop. Line --------------..------ <br /> LEACHING LINE [ ] No. of Lines I------------------------ Length of eachline---------------------------- Total Length .-----__.---.----------------�'j <br /> f 'D' Box ------------- Type Filter Material --------------------Depth Filter Material -----------------,-- ----------- <br /> Distance to nearest: Well ________________________ Foundation ----____-_______.__---_ Property Line. -----------_....__-._... P <br /> SEEPAGE PIT Depth Diameter ---------------- Number ------------------------ --- Rock Filled Yes ❑ No ❑ <br /> E Water Table Depth ------------------------------------- Rock Size <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -.-------------.--. - <br /> 1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date ---------------------------------- <br /> Y, <br /> --------------------------------- <br /> Septic Tank {Specify Requirements):-,------------------------------------------------------------------ ] ------ <br /> 4 .y <br /> Disposal Field (Specify Requirements) ----4,�_>—f ` <br /> . �p _: ��f 'l ` Oj i - <br /> ` ----------------------------------------------=-------------- --------- <br /> ---- --------------------------------------------------------- ------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 Workman's Compensation laws of California." <br /> ` Signed ' w <br /> ---- Owner <br /> --- - - Title ----------------I <br /> -- --------------------------- ----------------------- <br /> $y ---- ........ <br /> ------ f-other ---------------- --- - <br /> an r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ----- - -------- _ ' ------------. DATE _._ �._«_-`� -------------- -- <br /> ------------------------------------------------------------------ - <br /> BUILDINGPERMIT ISSUED --- --- ---------------------------------------------------------------i ---- DATE _..ADDITIONAL COMMENTS ----------------------------------- -----------------------------------------------=--------------------------- <br /> ---------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------- <br /> {� --- <br /> Final Inspection by. �_..--� -- Date ---. -- -la-- - -------------•------- <br /> ---- ----------------------- <br /> G SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. w C <br />