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FqR OFFICE USE: APPLICATION FOR SANITATION PERMIT � <br /> ---------------------------------- =---- q <br /> {Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From Date Issued Date Issued _L1:7f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and insta the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing R les and Regulations: <br /> JOB ADDRESS/LOCATIONli,4f. _: __.9_r VIP- rfV US TRACT -------------------------- <br /> / ` - . / y <br /> Owner's Name If7 � �fl ---- --------------- --.Phone <br /> ------------------------- <br /> Address + / �"C� ---------•--. City / ---------------------------------------- <br /> Contractor's Name . ____.License # /- , ` Phone � _---� 1� <br /> Installation will serve: Residence []Apartment House❑ Commercial <br /> Trailer Court <br /> Motel ❑ OtherXe2ZZ__ y / <br /> Number of living units.."'^�-r___-- Number of bedrooms ____________Garbage Grinder ------------ Lot Size -_______.__. <br /> Water Supply: Public System and name ----------------------a--------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑�/Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ N <br /> � <br /> Hardpan ElAdobe.E] IFill Material ----- ------ if yes, type ____________________________ b <br /> (Plot plan, showing size of lot, location of system in relation IVto wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if1public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_______ _____________ __________.___________ Liquid Depth _____________-___.__...._- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well -------------------------------------Foundation ---------------------- Prop. Line ___________________ <br /> LEACHING LINE [ ] No. of Lines ------------ ----------- Length of each line.,--I:';:___.__.______..______ Total Length ___________________________ <br /> 'D' Box ---- ------ Type Filter Material ____________________Depth Filter Material ----- -------------------------------------- <br /> Distance to nearest: Well ________________________ Foundation ________________________ Property Line __________________._____ <br /> F <br /> SEEPAGE PIT [ ] Depth -----_-_- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line _____---__---....-__-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----------------- -------------------- <br /> Disposal,Field .(Specify.Requirements)_ _/- - - ------ y�=e � `---------------------------- <br /> - 11 <br /> ---- ------- <br /> --------------------------------------------------- -- '-------------------------------------------------------------------------------------------------------------------------------------- <br /> 1 ` '%% <br /> --- -------------------------------------------------- --------------- ---------------------- -----------------------------------------I---------------------------------------------------- <br /> (Draw.existing and requiredaddition on reverse side) " <br /> I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Sfate Laws, and Rules andlRegulations of the San Joaquin local Health District. Home owner,or licen- <br /> sed agents signature certifies the following: 1i . <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 Workman's Compensation low's-of California." f <br /> Signerd ---- -------- - ------------ ----------------------------------- OwnerJ <br /> - <br /> BYs.2 ----------------------------------- Title __ �'< '-------------------------- - {1 <br /> of er than owner) <br /> 1 FOR DEPART ENT USE ONLYWU in ' <br /> APPLICATION ACCEPTED BY -- -------- - - -- ----------- ----- - ----------. DATE --`�I' 7 = <br /> BUILDING PERMIT ISSUED ---------------------------------- - -------------- -------DATE ------------------------------------------ { <br /> ADDITIONALCOMMENTS - ------- - -------------------------------------------------------------- ------------------ ---------- ---- ----------------------------------------- <br /> ---------------------_=--------------------------------------------------- <br /> ------------=---------------•--------------------------------;_:=--------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- <br /> .: <br /> s � - --------------------------------------------------------------------- ----------------------------------------- --------- <br /> --------------- ------------- -- F 'r' ------------------ <br /> Final Inspection b 4. --- ---- -- <br /> - -------------------- <br /> .� � �---- -------- Date � / ]--•---- <br /> SAN JOAQUIN ,LbCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />