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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - --------------- -------------- Permit No: <br /> 11 (Complete in Triplicate) <br /> I <br /> -----------------------------------------:--------I------ This Permit Expires 1 Year From Date Issued Date Issued <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 applicatioh is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> I� l <br /> ff ?_ � _ - _- P- <br /> ----JOB ADDRESS/LOCATI N __ CENSUS TRACT _____------------------- <br /> Owner's Name ----,/--- ''L`'`-�--------- ---------- Phone -------------------------------•---- <br /> Address ------ --------`-tG 1A CG ^ f =: City <br /> "' <br /> --5--g----3---�---�--- <br /> ------------ <br /> ----------------- - <br /> License PhoneContrac#or's Name ' <br /> Installation will serve: Residence yApartment House❑ Commercial: Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------- <br /> Number of living units:-------I__._ Number of bedrooms ________Garbage Grinder ------------ Lot Size __________ ----­--------- <br /> Water Supply: Public system and name ----------------------------------------------------------------------------------------------------------- Private t <br /> ii <br /> Character of soil to a dept ❑depth of 3 feet: Sand❑ Silt Clay Peat El Sandy Loam ❑ Clay Loam.0 <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type __-_______________________ <br /> (Plot plan, showing size:iof lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> I NEW INSTALLATION: (No septic tank or seepage pit permitted ifpublicsewer is available'within 200 feet,)' / N <br /> PACKAGE TREATMENT [J. ASEPTIC TANK'[ Size--- X_._.q___._--X__ -S--- Liquid Depth _.�-------- ---------- f/! <br /> Capacity �b-U 7 e- _: Material-__ Na. Com artment`s ,....-•-•--_----. LN <br /> UU <br /> Distance to nearest:_ Well ------------------------------_ ______Foundation ____C_O___i______ Prop. Line ____ .... ..... <br /> LEACHING LINE, (,N No. of Lines _________ - Length of each line-------- .0 0-_. ...... Total Length ------- --_a-:---___---_--_.-.-. <br /> ___-- ----- r --- ---D' Box ---- Type,.Filter Material - <br /> Distance to nearest: Well __ _�eta` >___-__ Foundation _- ----1�_/____---- Property Line ___________ __ _ <br /> -------- ' <br /> SEEPAGE PIT " Depth _....___:Z°r__ Diameter ___too <br /> —�_- Number ------------�-_-________,Rock Filled Yes No C] <br /> Water s <br /> �� Water Table, Depth ---------------- --�------- <br /> ,�. Rock Size ' X 3-- 1 <br /> I� 1 r <br /> Distance to nearest. Well _.___________ _Ge --._-__ _.,___,Foundation _.__I.0__________ Prop. Line ......:............... <br /> REPAIR./ADDITION(Prev. Sanitation Permit.#-.------------------------------------------- Date ________________...__-__________--) ' <br /> Septic Tank (Specify Rep uirements) ----------------------------------------------------------------------•-----•--------------=---:------- -------------------- <br /> Disposals{Field (Specify Requirements) ____________ __ <br /> = 11 1� - ------ ---------------------------••---------------------- <br /> --------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certifyr,that l have prepared this application and that the-work will.,be done in accordance with San Joaquin <br /> AI <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 macer <br /> as to become subject`to Wor n'-s Compensation laws of California." <br /> Signed ------- ------ ---------------I- -------- --- ----- ---- ------. -- Owner <br /> I <br /> BY I' -- ---------- = - Title <br /> ---JL1v-, ------------------------------ - ------------- <br /> (if other than owner) i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------- -----• DATE P r__.7 <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------- -----------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------•--------------------------------------- -----------------------------------=----------•--------------- <br /> J. <br /> --------------------- --------------------1------ --------------------------------------------------- ------------------- <br /> ----------------------------------------- --------Z---------------- ------------------------------------------------------------------------------------------------------...----- <br /> Final Inspection by: ------ _. . - - Date �l __� ____ �---------------- <br /> SAN <br /> __._.____ - _SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 511 <br />