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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No.. <br /> (Complete in Triplicate) <br /> ---------------------------------------------- This Permit Ex ices,].Year From Date Issued Date Issued <br /> - ----------------------------------- <br /> I---------------- <br /> Application is hereby Made to theSanJoaquin Local Health District for a permit 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 /> 'A - -----CENSUS TRACT -----6---- <br /> ----- ---------------------------- ------------ -TT, - <br /> JOB, ADDRESS/LOCATION ........ <br /> Owner's Name -------------a-,4--t---7--4Eh-----------------•------- ------------ <br /> ------- -------------------Phone ----------- <br /> Address --- -z-4�z-o-TA---A_,VCity A /,a -------------------- <br /> 0 ------- ------------------------- <br /> ------------------------ <br /> Contractor's Name ------ ',,:2"--- -cense # ------------------------- Phone <br /> Installation will serve: Residence E]Apartmen; House-E] 5ommercial,:E]Trailer Ge4o* <br /> Motel El Other ------------ <br /> Number of living units:--- ----- Number of bedrooms ------Garba-ge Grinder ----- Lot Size ----------------------- <br /> Water Supply-, Public System and name ----------------------------------- -----------------------------------------------------*---------------------Private <br /> Character of soil to a depth of 3 feet. Sand'E] Clay ❑ Peat EJ San oam;R Clay Loam 0 <br /> • Hardpan WTOO' Adobe ❑ Fill Material ------------ If yes,type ----------------------- - <br /> 1 •, <br /> (Plot <br /> -------- ---------------(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> t <br /> NEW INSTALLATION: (No septic tank or seepd' pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTICTANKW'-J Size-/-I-.Qg---- - -- <br /> ------------.-- Liquid Depth <br /> A� <br /> Capacity 12,49P------ Type Material--- No. Compartments ------ ------- <br /> Distance to nearest: Well --- ______________--------Foundation I------------------- Prop. Line _------------=---_--. <br /> --------------:------ <br /> LEACHING LINE k""No. of Lines' --- Length of each line-------6V ----------- Total ��gth -------��p----*--------- <br /> 'D' Box —/------ Type)F-,Iter Material J---d�-RqQ-k.Depth Filter Material --- <br /> ---------------------------------- <br /> Distance to nearest. Well --I---__________________ Founclation—'-.1-�6--------- ----- Property Line /_____-________------ <br /> SEEPAGE PIT Depth --Oel---------- Diamdlf�r ---------------- Number -----------I-------------- Rock Filled Yes R No 0 <br /> Water Tablet Depth ------ ------------------------------ -------Rock Size ------ ------------------------- <br /> JZ <br /> Distance to nearest, Well --- ------------------------Foundation --------- Prop. Line --.................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------I----------------------------------------------------------------------------------------------------wl------------------------ <br /> DisposalField (Specify Requirements) ---- ---------------------------------1----------------------------- ------------------------------------------------- --------------- <br /> . . --------- ------------------------ <br /> ------ ---- ----------------- -------:--------------------------------------- ---- -------------------- <br /> ------------------ <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 Son 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 beco 0 subject to Workman's Compe ation laws of CaWornia.' <br /> Signed --- --- ---------- ------- ------ ---------------- ---- --------- -4�- wner <br /> By --------i- --- ------ ---- - ------- ---------- Title -----------------------------------------:--------------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ----------- <br /> 'ACCEPTED BY -----9�-7 ------------- DATE <br /> APPLICATION - --;-9- I R,� !!----------------------------- <br /> BUILDINGPERMIT ISSUED ------------- -------- - ------------------------------ ----------------------------------------------DATE ----- ------------------------------------- <br /> ADDITIONALCOMMENTS ---------- ------------------------------------------------------------- ----------------------------------------------------------------------------------- <br /> -------------------------------------- -------------- <br /> ---------------------------------------- -- - -- --------------------- -- -e--- ------- --------------:-------- I . . <br /> ------- ------------- - ----- -------------------- ------- ------------------ --------------------------------------------------- <br /> --------------------------------------- <br /> ---------- <br /> ..... ... -- - --- -- - ----- ---- - --- --- ----------------- ------------ -------------------------�/------4�------- q <br /> -------------------------------------- <br /> -- <br /> Ins ------ -----------Date ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68'Rev. 5M <br />