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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .................................. ... <br /> Permit No �'. ��-_. <br /> �; <br /> {Jj/l�� Ii (Complete in Triplicate) <br /> ....................... 1j .. <br /> This Permit Expires 1 Year From bate 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/LOCA T •------------------ --------------------------------------------.-- CENSUS TRACT <br /> q <br /> Owner's Name ._. - --------------E-------- ------- Phone --.--•------------------------------ <br /> 5 / Yu r- <br /> 4 Addres .. --- �• City ----- `--.--------------------------------------------- <br /> Contractor's Name .... ___.License # __� _ phone -------------------__.......__ <br /> �.c <br /> Installation will serve: Residence partment House,❑_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 /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Gay C-] Peat❑ Sandy Loam lay-LoamC] <br /> :1 Hardpan ❑ Adobe '❑ Fill Material --- If yes, type___________________________ <br /> (Plot plan, showing size of lot„location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW 114STALLATION: (No eeptic..tank,or seepage-qit-,permitted if public.sewer is available within 200 feet,) 6N <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------------------------- ----- Liquid Depth -..------------_---------- <br /> �J <br /> Capacity --••--------------•- Type -------------- ' <br /> �.`... Material -------- No. Compartments - .................... r <br /> Distance• to.nearest.-Well -------------- -- -----------------.Foundation ---------------------- Prop. Line ---------------T------ <br /> LEACHING LINE No. of l --+ i <br />' j ] � �ines ________________________ Length of each line---------------------------- Total Length <br /> p D' Box <br /> I---- ------ Type Filter Material ....................Depth Filter Material ----------------_----'------------------_._ <br /> Distancelo nearest: Well -----------------•.-:--- Foundat.ion ------------------------ Property Line. ---------.---------=.__- <br /> - ­- <br /> 7--- <br /> SEEPAGE <br /> SEEPAGE PIT [ j Depth Diameter ________________ Number ---------------------------- Rock Filled,- Yes ❑ No 0 <br /> ..� <br /> Water Table Depth ---- <br /> --------- <br /> -------------------- Size ----------•--•---......... <br /> ---$-- <br /> Distance to nearest: Well ----=------------------------------------Foundation -------------------- Prop. Line -------.-----------.-- <br /> REPAIRVADDITION(Prev..Sanitati, r <br /> on Permit 3#-=------------------------------------------- Date ---------...........-------------•1 f. <br /> Septic Tank (Specify Requirements)___ ----------------------------- <br /> Disposal Field Specify Requirements] ----- ' ____-- --- -#'__----- ___-- - ----------- <br /> ------- <br /> --'d_ ------ <br /> ------------------------------ <br /> -- - - <br /> s <br /> II (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 accordan ce';m h San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health Distrix�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 airy person in such manner <br /> as to become subject to Workman' mpensation I f California." <br /> a <br /> Signed ---------------------------- ---- ---------------- ---- - ------- ----- Owner <br /> BY ---------------------------------- -- --- itle -----00611 --------- --------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ___ _ ____ Z 5 <br /> - ------------ ----- ----------------------------------- DATE la_______. ... --- <br /> ------------ <br /> BUILDING PERMIT ISSUED ----------------------------- --------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------- ------- ----------------------------------------------------------------------------:-----------------------I--------=------------------ <br /> --------------------------------- -------------------- --------------------------------- - --------- ------------------•---------------------------------------••-- <br /> ----------------------------- -- <br /> i' ------------------- ---------------------------------------------------------------------------------- — _ <br /> Final Inspection by: �..-� - Dater <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M• <br />� - u <br />