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FOR OFFICE USE: APPLICATIOM FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) Permit No. ----- -------' __ <br /> ------------ This Permit Expires 1 Year From Date 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 a plication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ar _ ->_ -E'� -< a---- F�1`����CCENSU TRACT --- ------ _---- --------- <br /> Owner's Name ----- '�./------14 L_eK---- � E' �e�G1d.Me.f1 -` �.. -------Phone ------ x, <br /> Address --------1X r-Z_0 <br /> ----- --1_-r' nG -- --------------------------------------- CitY ---------------------------------------------- <br /> ----------------- <br /> ---------------- -- -- ------ 1 <br /> Contractor's Name ---------�_ -_- T <br /> ----------------.License #A6Y1 Tr Phone <br /> Installation will serve: Residence jr;p:artZent Nouse❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other,-------------------------------------------- <br /> Number <br /> ------------- ----------------------------Number of living units:________ Number of bedrooms _.7-------Garbage Grinder ) - Lot Size <br /> Water Supply: Public System and name -___ __/ "&' -------W'cr"----1 ------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpan Adobe ❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <br /> _______________________ ___(Piot 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,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK'' Size_e_c_�_," ______________ Liquid Depth --A --__-____. ___ <br /> /� <br /> Capacity 'II6�_L__ Type fA � Material____ No. Compartments __ – <br /> ----- --- --------- <br /> Distance to nearest: Well --- ______________________Foundation _Z*� ___________ Prop. Line SS............______ <br /> LEACHING LINE J- No. of Lines _.2_--- ---------- Length of each line-----ffZS—------------- Total Length <br /> 'D' Box ----- Type Filter Material -__�_-____-____Depth Filter Material ____e _ _______________________ <br /> Distance to nearest: Well ____SW_._____._ Foundationl�'` ---_________ Property Line -+r_ ______._.___ <br /> SEEPAGE PIT Depth __�_�-�___ Diameter _s,?�°_--- Number ,Z- Rack Filled Yes No C,, <br /> Water Table Depth ----- ,%A'�-----------------------------------Rock Size --- - ----------------------- <br /> _ <br /> Distance to nearest: Well ----laa---------------------_Foundation ___��__�____ Prop. Line _.�_____�....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _________________________________________ Date __-___-___________________________} <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------- ---------------------------- <br /> Disposal Field (Specify Requirements) ______________________ __-----------_____.__________ <br /> --------------------------------------------------------------------------------- <br /> -------------------------------- ------------------I ----------------------------------------- <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 Workman's Compensation laws of California." <br /> Signed --------------------------- ---- ------------------------------ --- ---------------- Owner <br /> By --- / � Title <br /> - --------------------------- <br /> (If other than owner) <br /> S. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY __,/,4Z'.-- . - �' ------------------------------------ ----------------- DATE / ---------- ----- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ----------------------------------------- -- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------- --------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ________________________ ________ _______________ ___ -_.__-_- - A_._____.______________-_____-_____-________-.________-____-_______ ______________.__.___ ____.____ _-_______-_------------------- <br /> ----------------------------- <br /> ______- <br /> Final Inspection by: ------ � 1 ------ -- - --------------------------------- -------Date -�--- ------- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />