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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ <br /> (Complete in Triplicate) <br /> Permit No. __ � <br /> 91�'S <br /> _._____.__________._.______________________ This Permit Expires i! Year From Date Issued <br /> Date Issued _ld_�a__JL � <br /> a <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 /> JOB ADDRESS/LOCAT N --- .`�5! _ -!� <br /> -- � lC`� CENSUS TRACT ----------- <br /> j <br /> Owner's NameQ f ----------------------- ) P ne ----------•------•---•-----•---•--- <br /> Address - ----- - ----- ----- '—'—-- --• City -- �' r i <br /> Contractor's Name ----- �� -�-�� '_----- -- � - --- --_--___--.License # j3 _ Phone --------------------•---...... <br /> Installation will serve: Residence ❑ Apartment House[] Commercial XTrailer Court l❑ <br /> ;Motel ❑Other -------------------------------------------- <br /> Number of living units:-- Number of bedrooms ____-Garbage Grinder -.__-_ Lot Size -_______—_._______-___-___----___.__ <br /> Water Supply: Public System and name ----------------------------------- -------------------------- ------------------------------------------Private <br /> - <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam:❑ <br /> it 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,) \ <br /> PACKAGE TREATMENT ['] SEPTIC TANK ] Sized _----_-----_----_.____rY___"___________ Liquid Depth __________________________ <br /> Capacity _jZ� _c�lQ Type -------------- Mot eria l.: - -_---- No. Compartments <br /> Distance to nearest: Well --------- SQ °._ _._t_ -__Foundation _- lc_____________ Prop. Line ----S____--,___._- <br /> LI:ACHINGLINE {`j' No. of Lines -------/------------___ Length of each line- Total Length -------------- <br /> 'D' Box ---— Type Filter Material-_----59----".Depth Filter Material ---_ ---- <br /> - - --------------- ............... <br /> Distance to nearest: Well -------5P_ Foundation ---- -------- Property Line --- <br /> --------------------- <br /> SEEPAGE <br /> __---_________________SEEPAGE PIT [ J Depth ---.---e2__ ----- Diameter Number _____________. Rock Filled Yes No I❑ <br /> i <br /> _q_6-�Water Table Depth -O- <br /> { : f r• <br /> - _.__t_ ._..;Rock Size _- �__---- <br /> Foundation7_D___ _______-- Prop. Line ---- <br /> Distance to nearest: Well ------- 1-------------- - s_ ... ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ________..____ ------------------------------ Date ____-_______________________-____-} �.. <br /> Septic Tank (Specify Requirements) ----------------------- ------------------------------------------------------------ <br /> t Disposal Field (Specify Requirements) _____________ !° <br /> ----------------------------------------------------- - ----------------------------------------------------------------------------------------------------' <br /> C. . (Draw existing-andrequired 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 su ct to Workman's Compensation laws of California." <br /> �. --Signed � - ----- --- Owner <br /> By = -=' --- <br /> -- ---- Title . -- ----------- --- ----------- <br /> -ne7 -1. -f"- .,.-C-- ----- <br /> (If other than ovVner) FOR DEPARTMENT USE ONLY <br /> APPLICAT('dN ACCEPTEDr°BY DATE Q----- = <br /> BUILDING PERMIT ISSUED ------------- ---------- -------DATE - ----------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------ --------- --------------------------- <br /> u, <br /> ------------------- `----- ------- -------------------------------------------------------------------------- 1� ------------- <br /> FinalInspection by E'_.�,,----- ----------------------- ---•------------------------------------•--.Date - -- -------------1-�----•------- <br /> ii SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />