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FOR OFFICE USE: <br /> f t APPLICATION FOR SANITATION PERMIT r <br /> Permit No. <br /> (Complete in Triplicate) <br /> _ II This Permit Expires I Year Prom Date Issued Date Issued :_l_ __ .7 <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/LOCAT N� ..7_/P.A 0�:5�-------- s '�!�"°------------ - ------------------------------------CENSUS TRACT --------------- ----•----- <br /> Owner's Name :C-"& --------------------------------------------------------- ------ -- ------------------------Phone ------------------------------------ <br /> !l <br /> Address - ------- ------------ - -------------------------------------------- ------------ City ---- ----------------------------------------------------------------------- <br /> k <br /> Contractor's Name ''-I--- - -----------`�-+�----�s <br /> ---------------------------I----------License # ----------------- Phone ---------------------- ------- <br /> Installation will serve: Residence PlKpartment House❑ Commercial ❑Trailer Court IC7 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:__,_ ._ --n <br /> __-- Number of bedrooms _-- _-- _ Lot Size �-----_--::w,;.--------------------------- <br /> -- ----------- ------.-- <br /> _ <br /> Garbage Grinder _-_ <br /> Water Supply: Public System and name ------------------------------------------- ------------- ----------------------------Private <br /> Character of soil to a depthh of 3 feet: Sand'❑ Silt❑ Clay E] Peat [:] Sandy Loam F1Clay Loam ❑ <br /> Hardpan ❑ AdobeFill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size f of lot, 'location of system in relation to wells, buildings, etc. must be placed on reverse side.) C <br /> NEW INSTALLATION:' (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK'( ] Size------------------------------------------------ Liquid Depth ------------ _-..--------- S <br /> Capacity ---------------- Type -------------------- Material---------------------- No. Compartments -------=--- -•-_ <br /> Distance to <br /> nearest: Well -- °-------------------Foundation ---------------------- Prop. Line _------------:--.--•__ <br /> LEACHING LINE ( I No. of Lines "-`----- -__.______--_-- Length of each line---------------------------- Total Length ------------- <br /> --------------- �7 <br /> 'iD' Box '.--------- Type Filter Material-------------_-.-Depth Filter Material --------------------_-------------------- <br /> Distance to nearest: Well ------------------------ Founclati6ns------------------------ Property Line ---------- ---------- <br /> I�I <br /> SEEPAGE PIT [ ] Depth -Depth Diameter ----------------- Number ------------_-_------------ Rock Filled Yes E] No C]Water Table Depth -- ------------------------------------ --------Rock Size -------------------------------- <br /> i <br /> Distance to nearest: Well --------------------- ------------------Foundation ------------------- Prop. Line -------------I........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank {Specify Requirements) ------------- - ------------------------------------------------------------------------------------ M1 <br /> Disposal Field (Specify Requirements) -------------------- G� f� -----f----- -rn ------t'i�{�fh� ---------------------- <br /> 4 { = <br /> ---------- ------------------------------------------- --------------------------------------�------------------------ <br /> -------------------------------- - ---- --- -- ------------------------------------------------------------------------------------------------------------------------------- <br /> i - - (Draw existing and required addition on reverse side) <br /> I hereby certify that Ithve 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 sub' ct to Wor man's Comp nsatir laws of California." <br /> i Signed ___.___..__. ` - Owner » <br /> �! ----- ------ --------------------------- <br /> I I� <br /> By = ----------------------- Title ------------------------- ------------------------------ <br /> (if other than owner) <br /> R D P RTMENT USE ONLY <br /> APPLICATION ACCEPTED[BY ------ -- . �uu ------------------------------------ --------------- DATE ---- ��T �` ------------ <br /> BUILDING PERMIT ISSUED - -------- - - -- - - - --- - - - ------------------------------------- --------------DATE ------- ------------------ ---------------- <br /> ADDITIONALCOMMENTS = --------------------------- ---------------------------------------------- -------------- ------------------ <br /> ------------------------------ ------1---------------------------------------- -------------------------------------------------------------------------- --- - ----------------------- --------- <br /> ih <br /> ------------------------------ --- --- --h.� --- ---- <br /> Final Inspection by - Date . <br /> f I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />