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FOR OFFICE USE: .r' r ' <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------- ----. m (Complete3 Permit No. <br /> [Com lete in Tri licatelS T j e l <br /> ------------------------ p p <br /> ----------_--------- -------------------------_----.--- This Permit Expires 1 Year From Date Issued <br /> �1 � Hate 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 /> �'`� <br /> JOB ADDRESS/LOCATIOAfv�II))�_.__FY.-Q-5----R/A_5-----1-Zd-----------------------------------------------CENSUS TRACT -------------- ----------- <br /> Owner's Name - ----7-f -PJVf--------s�h dl!��tL--------------------------- <br /> y-- -------Phone <br /> Address +) A,/_/0 ------------------------------------- City --------------------------------------------- <br /> Contractor's Name -?'_._r !� ? ���P --------License - Phone <br /> ---------- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------ Number of bedrooms ----t�----Garbage Grinder ------------ Lot Size ----_______- <br /> Water Supply: Public System and name .------------------------------------------------------------------------------------------------------- ------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Sil�K Clay ❑ Peat❑ Sandy Loam ❑ Cloy Loam '[] <br /> 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 /> Q <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) to <br /> PACKAGE TREATMENT I I SEPTIC TANK:[ 7 Size------ Liquid Depth =T ��"'-_-___,___- <br /> Capacity `_ _U._-_ Type - - - 'i' ateriaiZ�.. o. Compartments .2_1_________________ <br /> Distance to nearest: Well _- __-____________Foundation _.-�.�__________ Prop. Line --- _ __________ <br /> LEACHING LINE [ ] No. of Lines ----.�-------------- Length of each fline____:__. �--___----- Tota! Length ____ 0--------- <br /> e_I� <br /> 'D' Box ------------ Type Filter Material _________________Depth Filter Material ---/_P_!!_ ...._-----------___--------- <br /> Distance to nearest: Well _____S !_____ Foundation _-_._,C__Q_.�______ Property Line. -- -- _____________ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- (tock filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------: :--------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ------ ---------- Prop. Line ---.---_.-------.---_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------- Date ------------------:---7-----------) <br /> SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------------------------•--------------------------- <br /> DisposalField (Specify Requirements) ---------•---------------•------------------------------------------------------ ---------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------- --------------------- ----------------------------------------------------------------- ------------ <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 to Workman's Compensation laws of California." <br /> Signed - Owner <br /> ;�6 <br /> By ------- L - Title ----------------------- <br /> ------------------------------------------------ <br /> (If other than owner) <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B ------------------------------------ DATE ______,/GP-_ 5----___Zd----_--- <br /> --- --------------------- ----------------------------- <br /> BUILDING PERMIT ISSUED __ _ -__.___DATE ______________________-_-__._ <br /> ------------------------------------------------------------------------------------------ --------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------------- ---------------- ------ ------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - -- --- ------------------------------------------------------ --- <br /> --------------------------------------------------------------- <br /> ---- -- _- ---- --- <br /> Final Inspection by: -----------------------------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />