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FOR OFFICE USE: APPLICATION jFOR SANITATION PERMIT <br /> ----- --- ---- ---------------------------------------- r _ eco <br /> (Complete in Triplicate] Permit Na: ____ <br /> --------------------------------------------------------- <br /> `"' ----- This Permit Expires 1 Year From Date Issued Date Issued --- _-/-f�_jy <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/LOC N . / �`� J1---��,�� r------------1- Gs R..-----CENSUS TRACT y 7 ------ <br /> -- _ `- �------------- <br /> / p <br /> Phone Owner's Name <br /> � _ __ City ` ----------------------------- <br /> ------ ----------- ----- ----r----------- <br /> r #Contractor's Name - Phone ---------_----- -- -- ------- <br /> Address <br /> - ---Address --- ----------- <br /> Installation will serve: ,.,..Residence VApartment House❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑Other ---------------------------------- <br /> Number of living units:__________ Number of bedrooms ______Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> Water <br /> ____________ _ ----"`Water Supply: Public System and name ----------a---------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet:. SandE]. Silt❑ Clay,E] 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 <br /> public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size- .____rs___ _ ___--.__x__ __.______ Liquid Depth ---`CrZ_________________ �. <br /> Capacity __ Type ,.sc i1�.4 Materid f5 +�' -L__r_._ No. Compartments .___ I <br /> e Distance to Weare t: Well -____-_- --- <br /> ---- _.____1_ _�____ Prop. Line` ---------- Q <br /> LEACHING LINE "` No. of Lines _._________ <br /> ---------- Length of each line---------`/Ct-----____-- Total Length ------- - .......... <br /> 'D' Box ----1------ Type Filter Material ------i __1�__Depth Filter Material ------------j?____. ___________ <br /> Distance to nearest: Well ...._______ Foundation ----- ?__I-_-_______ Property Line --'_�g_________________ <br /> SEEPAGE PIT ] Depth __4Z`= _-___ Diameter _33---- Number --------------- ____-_ Rock Filled Yes , No ❑ <br /> V <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) -----------------------------••------------------------------------------------------------------------------------------•----------- <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 <br /> as to become subject to War a ') Compensa laws of California." <br /> o <br /> Signed ------------------------------ - / - ------------------ Owner <br /> BY -------------- �'t f---- - Title . (- t 5 1 <br /> (If other t caner) <br /> FOR DEPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY ______________ DATE --_f__.: j�_"-- ------------ <br /> - ----- -- - - -- ---------------------------------------------- <br /> BUILDING PERMIT ISSUED -------------------- -------------------------------- -------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------- --- ------- ----------------------------------------------------------------- ------------------------------------------------------------------------------ <br /> ----------------------------- ------- = <br /> ----- <br /> Final Inspection b ___.Date ��_- - �D --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />