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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Q <br /> --------- --------------- ---- Permit No.xg ' <br /> ------------ (Complete in Triplicate) -- ----� <br /> ---------=----------------------------------------------- This <br /> ----------------------------- -------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued _—_4"157 <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> i 5-17 Y1 J, ----------- <br /> JOB ADDRESS/LOCA -! -..---- ----- CENSUS TRACT -------------------------- <br /> ----------------------------`- ----- - --�- --------------- <br /> Owner's Name ' t�� ��.�------- ---------Phone --------------------------------- <br /> .� 7-9r �t/ 1 - - ---------------------------------------------------------- <br /> --- <br /> ------------------------------- <br /> Address City <br /> Contractor's Name R I --- -----.-- - � License # /V .3!4' Phone ----------------------------- <br /> Installation will serve: Residenc ❑ Apartment House❑ Commercial []Trailer Court <br /> Motel ❑ Other ------- ------------- <br /> Number of living units:--_r Number of bedrooms ---------- Grinder ___ - Lot Size ------------------------------- ------------ <br /> Water Supply: Public System and name --------------------- ------------------------- --------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt ❑ Clay C�( Peat❑ Sandy Loam -[] Clay 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size----------------------------------------........ Liquid Depth -------------------------- <br /> Capacity <br /> -------- ------Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ ---------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -..-.-------..----...- <br /> LEACHING LINE [ ] No, of Lines ------------------------ Length of each line------------ --------------- Total Length ----------- ---------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -.___-_......---.-.--_--__--.-.-.-..------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -----..-----.-.---.----- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line -----------.-------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----..----..--.--.-.-.--..-----.-.) <br /> SepticTank (Specify Requirements) -------- -------------------------------------------------- ---------------- -------------------------- .. ------ - ----- <br /> Disposal Field (Specify Requirements) ------------. f.� =------- + X ` <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 Son 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 beco a ubject to Workman's Compensation laws of California." <br /> Signed ------ <br /> --------- Owner <br /> BY ---- YY =------------------------------- Title t_' �-t�---------------------- <br /> {If other than own r) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- --------------------------------------------------------- DATE _a -� �� ------------ - <br /> BUILDING PERMIT ISSUED --------------------------------------------------------------------------- ------------- ------- ---- <br /> ----DATE ------------------------------------------- <br /> - - <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------------------- --------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- <br /> ---- <br /> ---------------------- ---------------------- <br /> ___________________ ______________________________ E- ._.-....--_.............. -......- ....----...--..........___-_____ ___._..-.... ----- - ._.......... -___-___- <br /> Final Inspection by: <br /> Date " . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> gH 9 <br /> l-'68 Rev. 5M f <br />