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FOR OFFICE USE: <br /> -= APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------- Permit No. <br /> (Complete in Triplicate) <br /> 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 application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --- -- ----------------------------- -----------------------------------I------------------CENSUS TRACT -------------------- <br /> Owner's Name -------t�Xu --as 10, /11,-__ / r------------------------------------ <br /> --------------------Phone --------------------_--------------- <br /> Address ------ ---------- --------------- -------------------------------------. City ------- ------------------------ ------------------------------------------- <br /> - PhoneContractor's Name ----- --------------------------- ----- - -- ---- --.License # <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 'E] <br /> r a. _ <br /> Motel ❑ Other -------------------------------------------- F <br /> Number of living units:--__ ___.__ Number of bedrooms __:_____Garbage Grinder ------------ Lot Size ---------I----------------------------------- <br /> d <br /> Water Supply:;Pulolic System and name ---------------------------------------------------------------------- ----------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe'❑ 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] Size_____________________-_._-_--------- _____._ Liquid Depth -------------------------- <br /> Capacity --------------- Type =- ------------ M'afieriaL No. Compartments ----...._...---------. <br /> Distance to nearest: Well ---------t--------------------------Foundation --- ------------------ Prop. Line --------------........ <br /> LEACHING LINE [ ] No,lof Lines ________________________ Length of each line---------------------------- Total Length ' <br /> _ F <br /> 'D' Box ------------ Type Filter Material ----------c---------Depth Filter Material -------------------------------------------- <br /> Distance <br /> ___.______ __ -____._Distance to nearest: Well ------------------------ Foundation _.___________ ---------- Property Line ________-_________._.__. l <br /> SEEPAGE PIT .[ I Depth -- ----------------- Diameter ________________ Number --------------------- _=t Rock Filled Yes ❑ No <br /> Water Table Depth ___ Rock Size <br /> Distance to -near est: Well ----------------------------------------Foundation -----_____j__------ Prop. Line ----_--------.------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------- ------------_) Y <br /> Septic Tank !(Specify Requirements) -------------------------------------------------- -------------------- --------------- <br /> � � -G - ------ --# <br /> Disposal Field' (Specify Req uirem ents)-7_*_' s --� _$ X-_ _ _. -t +-1'-_ __________________________ <br /> ---------------___1 <br /> -1---------------------------- �- ---------- -- ----------- ---------------------------------- -------- `------------------------------------------------- <br /> (Draw existing and required ddition on reverse side) <br /> I hereby certify that I have p,r pared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rule ulations of. he San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the followi g: `3 t I <br /> "I certify"thct in rforma °e th wo�for ich tds p rmit is issued, I shall not employ any person in such manner <br /> as to becom j o Wor an 7' r nsati.o a a 4ornia." E <br /> Signed - - ----------------- --- '-- I--- Owner <br /> (If of er than o er) <br /> FO DEP AR °MENT USE ONLY, �; 1 <br /> APPLICATION ACCEPTED BY --- �� --------- ---------------------------------------------` :DATE -- �J S---T 2Z--------- <br /> ING PERMIT ISSUED <br /> ADIDIDTIONAL COMMENTS -------=�a� —ae f' --G�'----,..`�----DATE------------- (- - <br /> 4 <br /> --------------------------------- ---- __ <br /> ---------------------------------------------------------------------------------------{--------------------------- <br /> ----- ------------- ------ <br /> -- - - - - -------------------•--- <br /> Final Inspection by - -_ Date f�� � - - ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M _. , <br />