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OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- -------------------- Permit No: <br /> - � {Complete in Triplicate} <br /> --- -------------------------------------------- :-'------------- This Permit Expires 1 Year From Date Issc`{ 7 ti 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 /> compliance with County Ordinance No. 349 and existing Rules and Regulations: r <br /> c- • : <br /> JOB ADDRESS LO ION " <br /> / 4 �' c^ -�-�" CENSUS TRACT -- <br /> Owner's Name <br /> ,,. - - Pone <br /> ---------------Name --------------- <br /> /j <br /> Address -7 7-± - � '`�!1 -------- City - ---- -e- � <br /> � S / 1 <br /> Contractor's Name ` = ------------------ ----------------------------------- -----.License # ------- -: ------------- one ------------------------------ <br /> Installation w,ll serve- Residence ❑ Apartment Mouse,❑ Co mercial:❑Trailer Court ',❑ <br /> Motel ❑Other -_ff?A �-_- -- <br /> Number of living units------------- Number of bedrooms -- -_.Garbage Grinder -___ t Size --_---_�__3__ <br /> d- 5 <br /> Water Supply: Public 5 stem and name _-_----_-_s___ € l <br /> - I <br /> pp Y y r' .., Private ❑ <br />• t <br /> Character of soil to a depth of 3 feet: Sand' a Sil#❑ Clay ❑ Peat ❑ Sandy Loam ❑ ;;Clay,Loam > � <br /> _- - Hardpan E 7Adobe❑` 'Fill•Material --......... )If Yes,t - i�. <br /> ---- --------------------- <br /> (Plot.plan, showing size of lot, location of system -in relation to wells, buildings; ec. 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 I ] Size------------------ -- ---------- ------------ Liquid Depth --------------------------� <br /> Capacity _ Q. ype S_________ ___ aterialt ----- No. Compartments _- --.........-_ <br /> Distance to nearest: ell ----/ 0 t--------Foundation , Prop. Line <br /> LEACHING UNE [ ] No. of Lines ---------- ------------ Length of each line---_.f0��o____ Total Length --- -"------.__ <br /> q <br /> 'D' Box ------------ Type Filter Material -_Depth Filter Material ------_51-7-�----_---_ <br /> Distance to nearest: �s `-= ---- Foundation <br /> on3 ' Property <br /> SEEPAGE PIT Depth ------------ ---- Da�� Nurnber ---------.-_ .__-- Rock FiledYes No <br /> Water Table Depth -------------------------------------------------1�V u <br /> Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foun�ation -------------------- Prop. Line -------------- ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date/---------------------------------- <br /> SepticTank (Specify Requirements) ------------:----------------------------------------------------i------------------------------------------------------------------------ <br /> Disposal <br /> ------- --------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) -----------=------------------------------------------------------------------------------------ <br /> ------------------------------------------------------ ---------------------------------------------- ---------------------------------------------------- ------ <br /> f <br /> ------------- --------------------------------------------- <br /> --------------------------------------------------------------�- (Draw existing and required addition on!reverse side) <br /> �,..1._hergby.certify_that..I have prepared-this application and`rthat-th 'week!will-be donieln -accordance with San Joaquin <br /> County .Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local health District. Home owner or iicen. <br /> sed agents signature certifies the following. i <br /> "I certify that in the performance of46.'work for which ht s1 permit iIs i sued, I shall not employ any person in such manner <br /> .. <br /> F as to subject-to Workman s C mpensatlon laws of California." ' <br /> 4r <br /> 1 I <br /> ti � a �� <br /> Signed -- -----A��-•---- � weer � <br /> O <br /> By -------------------------------- ._ <br /> ° Title <br /> (If other than owner]: ° <br /> FOR DEPARTMENT USE ONLY <br /> BUILDINGPERMIT ISSUED ----------------------------------- ---------------------------------------------------------------------DATE -..----------•---7�. --------------- <br /> ADDITION --- <br /> APPLICATION ACCEPTED BY -_.__- r -_- <br /> ------------------•---- -------------------- --------------. DATE <br /> AL COMMENTS -------------------- <br /> ----- - <br /> - <br /> ---------------------- ------_-_--------------------------------------------------------------------------------------------------- ----------------------------------:. <br /> ------------------ " • f a > <br /> Final Inspection by: ------ --:---_•-_-___- <br /> Dat - <br /> e --- <br /> SAN JOAQUIN IOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />