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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 57 <br /> (Complete in Triplicate) Permit No. -._7 __.__S__ <br /> _______________ This Permit Expires 1 Year From Date Issued 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 /> described. This application is made in compliance with County Ordinance N . 549 and existing(Rules nd Regulations: <br /> G( L <br /> � _C7¢C[�,�-c 1f`-d - CENSUS TRACT <br /> JOB ADDRESS/LOCA !ON .__ ------t_.- ----------- - ----- --- -- .....----- <br /> Owner's Name - -------------------------------------------------------- ------ ---; --- P on <br /> Address f j' -- --'�-`----- ---... Cit ._-------------------'�` --------------------- <br /> Contractor's Name ------------------------------- ------ ------- --------------------------.License # ------- - ------ Phone ------------------------------ <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------.----- Number of bedrooms &Z-----Garbage Grinder ------------ Lot Size ____________________________________________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'PI-I'silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Mpterial - ---------- 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 f ] Size______________________________________________ Liquid Depth -------------------------- <br /> Capacity <br /> ____________-__-___-__Ca acit _ Material______________________ No. Compartments ___________ <br /> N <br /> Distance to nearest: Well _____________________________.____-Foundation ------------------ --- Prop. Line __-._..:----____-_____ 0 <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length __-___-____-__:----.---___-_ <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -- ----------------------------------------- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _______________-__--._-_ O <br /> SEEPAGE PIT [ ) Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- ,9► <br /> Distance to nearest: Well ----------------------------------------Foundation ------ Prop. Line ---------------...... Vj <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ________ __________________________________ Date --------------.___________________) �.- <br /> Septic Tank (Specify Requirements) -------/------------------- _ --- ------------------------------.•---------------- ------- <br /> Dis sal Field {Specify Requirements) --------0_0 --- --�� -------- --{"'�"` � -------- <br /> ------ . --z --------------==---- .------------------------------------------ ---=-- <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 San Joaquid <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. biome 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 become subject tark ns Compensation laws of California." <br /> Signed - -----__. Owner <br /> -- -- -- <br /> BY ----- ---- -------------------------------------------------------------------------------------------- -Title --------------------------- -------------------------------------------- <br /> (If other than owner) <br /> FOR DEPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.- �-r -------------------------- DATE -- G 7 --------------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE --------- ---•-------------------------- <br /> ADDITIONAL COMMENTS ----------------------------------- -------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- ------------------------------------ ------------------N------------------------------------------------------------ --- ------------------------------------------------------------------------.. <br /> ------------------------ ---------- <br /> - - - - -- ------------------------- <br /> - ------------------------------------------------------------ --- ---- ---------- - <br /> Final Inspection by: .__. _ r_- _ ____ '------------ ----- <br /> -- - �- --------------------------------- -•------ - ---------------Date . _`�_.__��-�-�- - ---- ---- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />