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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT n� <br /> - -------------------------------------- <br /> 11 (Comple.Q in Triplicate) Permit No. <br /> ---------------------------------------------- % <br /> 1. <br /> �t-__ This Permit Expires 1 Year From Date Issued Date Issued <br /> - -- -------------------------------------=--------- <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-'JN-made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> y <br /> CENSUS TRACT nDLOTION ------------------- -------------- ---------- <br /> Owner's <br /> ------- <br /> Owers Name _ ----- ---- ---Phone zT <br /> ------- <br /> Address3 ----- ` ------------------------------------------------------------ City ---- ------ --------------------------------------------- <br /> Contractor's Name --G2-�'''� "' '` -------------- ------------------------------License # ----- - - --- ---------- Phone -------------- --------------- <br /> I <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial []Trailer Court ',❑ <br /> ! Motel F-1Other ------------------------------------------- <br /> .-_ <br /> Number of living units:__? <br /> ,II_____ Number of b�eddrooms _________Garbage Grinder ------�.___._ Lot Size -lmx.__r_3 ------------------- <br /> Water Supply: Public Systemand name ___P414&------------------ ------------------------------------------------------------------------Private ElCharacter of soil to a depthlof 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Gay Loam ❑ <br /> Hardpan ❑ Adobe X 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,) NNI <br /> PACKAGE TREATMENT { ] SEPTIC TANK:( ] _U-- ----_________._._______ Liquid Depth __________________________ <br /> Capacity -------- Type CPM_9,V'F_ Material______________ _______ No. Compartments ------------- <br /> Distance to nearest: Well _-/LfQ_)Cr------------------Foundation -Jw_ ----------- Prop. Line <br /> IM r <br /> LEACHING LINE [ ] No. of Lines __________________ Length of each line_.9d__ _ff_------___ Total Length ,! - __.____._..___.___. <br /> �l <br /> 'D1f Box ___1------- Type Filter Material _u?OC/�--------Depth Filter Material :--1d_k --------_---------I...... <br /> Distance to nearest: Well ------- a T-: Foundation A_/2r----------- Property Line _,:r - <br /> II �-__x <br /> SEEPAGE PIT [ ] Depth /01-7T------- Diameter _r_______ Number --------------------- Rock Filled Yes ;K No 0 <br /> I <br /> Water Table Depth -=----------------------------------------------Rock Size __ __---a_-..------ -------- <br /> Distance to nearest: Well l -----------------------Foundation _____ Prop. Line 57—Jr— __-__- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -_----------------•---------------} <br /> SepticTank (Specify Requirements) -------- -----------------------------------------------------------------------------------------------------• ---------------------------- <br /> Disposal Field (Specify (Requirements) <br /> -------------------------------------------- <br /> -------------------------- ---- --- -------------------------------------------------------------------------------------------------------------------------------------•----- <br />' ------------------------------------•-''--- ------------ -- ------------------------ --------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I havle 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 J6aquin_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 Workma s Compensation laws of California." <br /> I a <br /> Signed C ------ WOwner <br /> By ------------------- ------ --------I`-------------- ----------------------------- --- -------------- Title -----:---------------------------- ------------------------------------- <br /> - <br /> (If other than`owner) <br /> 'II OR DEP °1i tT ENT USE ONLY <br /> �i. <br /> APPLICATION ACCEPTED BY fV <br /> - ---------------------------------- DATE --- - - <br /> BUILDING PERMIT ISSUED(----_ ___DATE --- -------- <br /> ADDITIONALCOMMENTS!M-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------1I--------------- <br /> ------------------ <br /> ---- -------------------------- ------------------------- <br /> = --- <br /> ! Final Inspection by: ---- ---- i- �'� �` r��---- <br /> -- ----------------------------------------------- - -----.Date ----- --------3-- - ---��-------- -- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E.H. 9 1-'68 Rev. 5M <br />