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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �d , <br /> - 1. Permit No. --- <br /> ------------- <br /> (Complete in Triplicate) <br /> _________________________________________________________ 5 { <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 application is made in compliarice ith Count Ordinance ��a Rules and Regulations: <br /> ,.q �"' v�,ti.rW s r— Q 1 <br /> JOB ADDRESS/LOC T N a �iS t !`�''c------ .?0-_-�--------- US TRACT -------------------------- <br /> i <br /> Owner's Name -- --- -- - -- -------------Phone ---- __ r <br /> Address .13-9-0 <br /> � ` <br /> - 4 --------- - -- ---- -. City <br /> Contractor's Name ---------------- -.- I--- - - ------------ -------------------------.---License # -- - �------ Phone 0%2_41' _ <br /> Installation will serve: Reside nce5�Apartm nt House(❑ Commercial :❑Trailer Court ❑ I <br /> Motel ❑ Other -------------------------------------------- aai�rr /��� <br /> Number of living units:----/_--_- Number of bedrooms-3_____Garbage Grinder ---__---__-. Lot Size __c;S.__,0eA��,. __________________ <br /> Water Supply: Public System and name ------------------------------•-•--• -- -------------------------------------- --------------- Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> !_ <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If Yes,type ---------------------------- <br /> (Plot <br /> ------ --(Plot plan, showing size of lot, location of system tin relation to wells, buildings, etc. must be placed on reverse side.) O <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] i Size------------------------------------------------ Liquid Depth ---_-_--_-___-__---,___- 1 <br /> Capacity ------ -------- Type --'------------------ Material---------------------- No. Compartments .................... <br /> Distance to nearest: Well ________Foundation ----- ---------------- # <br /> --�------------------------- - --- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines - _____.____ Length of each line_______________________ Total Length <br /> D' Box ------------ Type Filter Material --------------------Depth Filter Material -----------_---------_.___......._......__- \� <br /> -- ------- ; <br /> Distance to nearest: Well ____________________.-__'Foun�atio`n"_"_---___-_________ Property Line ____. ------------------- Z <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter _____________ Number ---------------------------- Rock Filled Yes No <br /> Water Table Depth -------------------------------------`-----------Rock Size -------------------------------- <br /> .n .� <br /> t Distance`—to nearest� : Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION{Prev, Sanitation Permit#-___-___.___...___________________________ Date ________.--_______________________) I <br /> Septic Tank (Specify.Requirements) `------------- -- -------------- ----------- ----------- <br /> Disp sal F' 1 .. ____-- -- __-- ----- - ---------� -��-`/-----------•---•- <br /> ---------- <br /> pe ire <br /> � . q ------------------_------------------------ <br /> I - ---- <br /> --------------------------------------------------------------------------------------- <br /> (Draw existing 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 si nature certifies the foil ling: <br /> "1 certify :hs <br /> t i the performance of th work for which this ermit is issued, I shall not employ any person in such manner <br /> as to beco bject to Wor man's pen 4tion laws California." f <br /> Signed ------------- ----------------------- -•- ---- ------ ---- --- ---- - -1---- <br /> BY ------------ - - ---- Title <br /> - ------------- -- -- ------- <br /> --- --- ---- - - -- <br /> ------------ ----------------------------------------- <br /> (If other than owner] <br /> FOR DE ARTMENT qSE NL } <br /> APPLICATION ACCEPTED BY ------------------------- -- -------- --- --- ------- DATE ... �' - Q <br /> BUILDING PERMIT ISSUED ------ DAT <br /> ADDITIONAL COMMENTS ------------------------- --------------------------- - <br /> ------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - ------------------------------- --------------------------------------------------------------------------------------------------- ----------- - --- -- --- <br /> ------ ------ - -- -------------------------------------------------------------------------------------------------- <br /> - - ----- ------- <br /> Final Inspection by Date /5 <br /> SAN JOAQUIN LOCAL HEAL DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />