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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------- --- ------------------------------------- Permit No: -7-�:-S-S-- <br /> (Complete in Triplicate) <br /> ---------------- --- -- ------------------------------- <br /> - ------- <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/LOCATION`.--- -��5� _ .._-� : _. _ - --------CENSUS TRACT ------------------------ <br /> , '/ . <br /> -- <br /> Owner's Name ---- N - - ---- ---- --------- --- -- --------------------- ------ ------------------Phone ------------------------------------ <br /> Address --- ICity - -------------------------------------------------------- <br /> Jl <br /> Contractor's Name -- --.License #/_ _J'. Phone ------------------- ---------- <br /> Installation will serve: Residen Apartment House'C7 Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:--- __/____ Number of bedrooms - ---;__Garbage Grinder _ Lot Size -_ -- ___________ <br /> Water Supply: Public System and name ------- ------------------------------------------------------------------------------------------------------Private <br /> .r~ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam D?,'- <br /> Hardpan ❑ Adobe Fill Material If yes, type -----------------=�.________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildinds,".etc, must be placed on reverse side.) <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 ----------------_--------- <br /> Capacity -------------------- Type ---------- Material------------------_-- No. Compartments ....................... <br /> Distance to nearest: Well ------------------------------------Foundation --_- ----------------- Prop. Line .___.___-____:__._____ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line --------------------------- Tota) Length --------- ------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------- -------------------- <br /> Distance to nearest: Well ------------------------ Foundation -------------------- --- Property Line --- 1 <br /> SEEPAGE PIT [ ] Depth ------ ------------- Diameter _- ----------- Number ---------------------------- Rock Filled Yes ❑ No i❑ j� <br /> Water Table Depth ------ --- ------ ------------------------------Rock Size -------------------------------- C R <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ________-________--__ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ------------------_.-----_--------) <br /> Septic Tank (Specify Requirements) =------------------------------------------------------------------------------- --------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------ <br /> .- ------------------/oQ- '--__ � <br /> -- <br /> ----------------- -- --------.-------------------------------------------------------- -------------------- <br /> (Draw existing and 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 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 i <br /> as to become subject to Workman's Compensation laws of California. <br /> Signed ---- ------------------------------ Owner <br /> ------------------------- <br /> (If other than owner) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ------ ----------------- ------------------------------------------------------------------. DATE �----------------------------------- <br /> BUILDINGPERMIT ISSUED - - - -------------------------------------------------- ---- ------------------------------DATE ------------------------------ ------------ <br /> ADDITIONAL COMMENTS --- <br /> --------------------------------------- --- -------------•------------------------------------------------------ ---------------------- ------------------------------------------------------ <br /> ------ -- --- --- ------------------�16 _-'Tc <br /> ----------------------------------- ------------------------------------------------------------------- ---------------------------------------- I <br /> ------------------------------- ----- - ------ <br /> Final Inspection by: -- - -----.Date <br /> _... f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />