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_FOR OFFICE USE: -� <br /> �-.' APPLICATION FOR SANITATION PERMIT cc33 <br /> ==--------------------------- ------ Permit No, <br /> �( (Complete in Triplicate) <br /> ---------=-- ------- ------------------------------------ 1\ <br /> '` Date Issued ---- <br /> --- ----------------------_--_-_-_------__------------_ This Permit Expires ] Year From 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 com fiance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LO . ION . � --,-,----------------- -- ---CENSUS TRACT -------------------------- <br /> Owner's Name �� - = �r �/7�sff -------Phone ------------------------------------ <br /> Address ------------- '� ---- ---- � # �` City - e�-- ---------------- ---------•---�-'6, <br /> W <br /> Contractor's Name __ ._ a� �' --------------------=---------License # - �' - Phone�L�{__•___��_-_ <br /> Installation will serve: ResidenceXApartment House'❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ------------ --------------------- --------- <br /> Number of living units:.-/----- Number of bedrooms ______Garbage Grinder - Lot Size_104, ___'_____________ <br /> ---------------------------------------Private <br /> Water Supply:•Public System and name ❑ <br /> Character of soil to a depth of'3 feet: S'and'❑ Silt❑ Clay .(Peat❑l Sandy Loam ❑ CI y Loam <br /> f <br /> r._,.Ho dpan ❑ Adobe;e Fill Material ------------- If yes,type ---------________-________ <br /> 3 <br /> (Plot plan, showing size of lot; location of system in relation to wells, buildings, etc, must be placed-on reverse side.) N.. <br /> NEW INSTALLATION: (No sep c tank or seepage pit permitted if public sewer is available within 200,feet,) t <br /> Ir .�» r <br /> PACKAGE TREATMENT--[-]-5 ..'IC TANK Size- _ -------I------------- Liquid Depth .----------•--- <br /> Capacity ------ TYpe,—:1._Q- Material �a , �--- No.�ompartments --`------ <br /> Distance;to nearest: Well ----- 0------------------------Foundation _-9- _________- Prop. Line -- _-_------_. <br /> OF <br /> LEACHING LIME No. of Lines ___, _________ Length of e ch line__ _ __ __� <br /> _�---__ ----- Len Total Length � -------------- <br /> _ ._ <br /> t i 'D' Box _ ,.O Type Filter Material ' �_ _ _ __Depth Filter Material ___________ _______ <br /> -A .. Distan 3to nearest: Well ------r"---------- Foundation1f- --_________ Property 'Line. _ -.--...__..... <br /> SEEPAGE PIT; -Dep h �---- i -- -- Number --------- <br /> }� �--- __ '?�-___________ Rock Filled Yes ` No i❑ <br /> _ _ Diameter. _ , <br /> Water Table Depth ------ V--- <br /> ..)tock Size, " 1'� <br /> Distance to.nearest: Well _________________________._ ---------- ------------ Prop. Line __._----------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------------------ Date -----_--------------.--.---.------1� r <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------------.•---------- •---------- <br /> Disposal F efd4{S_pecify Requirements) ----------------------------------------------------------- -----------------------------------------------•----------- <br /> r��Y <br /> `-C <br /> ____________________________________________________________________­________________________ <br /> L <br /> _----------- - ----_.__________ _.____-____________._.._----________________________________________--______- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work3vill be done in accordance with San Joaquin <br /> County Ordinances;Stdte Lnws, and Rules and Regulations of the San Jo q in 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 issuee, I shall not employ any person in such mannee <br /> as to become subject to Workman's Compensation laws <br /> � of-California.'_' <br /> J,Signed -------- ----- --- -------------- Owne- <br /> r <br /> BY -------------------- ------------------------------------------ Title ` <br /> oth an owner) ' <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ./ACCEPTED BY ._ ' DATE --- <br /> -------------- <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------- a - ------DATE --------------------------- <br /> ADDITIONALCOMMENTS ------------------------- -------------------------------- ------------------------------------------------------------------------ ------------------------- - <br /> ------------- ----------------------------------------------------------------------- ----------------------=------------- --------------------------------------- L------------- <br /> ------------------------------------ .s __.___ __.._______ _ _ __._ _____________ _ _ __ ___ f <br /> _ _ _ _ _ ________ <br /> Final Inspection by: �� rt - Date ------ " - -- - ----.--- <br /> - -------- ----------------- ----------------- ----------- <br /> - - ---------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1- 68JRev75M- <br /> _ 1 <br />