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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i,� z <br /> ------- -------- ------ Permit No.rx _o?��. <br /> ---------------- <br /> �` [Complete in Triplicatel� <br /> _------------------------------------------ <br /> � <br /> --_----------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> IL!-!- <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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ----------------------------CENSUS TRACT ---------- --------------- <br /> JOB ADDRESS/LOCATION ® 1 - -------- -_ -- - <br /> Owner's Name ----------- Phone. ,_7_ -------- <br /> ----------------------------- -------- - <br /> Address ----- --- --------------------� ---Q- -------- I--------- ---- 'r�City7 ----------------- <br /> : _ - L cense•#/k1,AYf-�-_Phone <br /> Contractor's Name ------------- ---- -' -- <br /> Residence1rtment House' Commercial ❑Trailer Court i❑ <br /> Installation will serve: P ❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number <br /> ---------------------- ------Number of living units:----(__----- Number of bedrooms _--_ .Garbage Grinder --C ----- Lot Size -_-X- fl---------------- <br /> Water Supply: Public System and name ----- I-------------------- ---------------------- -- -------------------- -----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 n'reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) "r <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size____________________---------------__.----------- Liquid Depth -------------------- <br /> Capacity --------------- -- Type - - ---------------- Material---------------------- No. Compartments --------------- •----- <br /> Distance to nearest: Well ___________________-______--_-.----Foundation ----------------------.Prop. Line _________._..-.______ I <br /> LEACHING LINE [ ] No. of Lines __________ _____________ Length of each line---------------------------- Total Length -----------.--_-__________- <br /> 'D' Box -------- __ Type Filter Material --------------------Depth Filter Material -- ------------------------------------ <br /> Dista <br /> --------------------------------- j <br /> Distance to nearest: Well --- ------------ Foundation ------------------------ Property Line ___________--______--- <br /> . 1 jc <br /> SEEPAGE PIT [ ] Depth ------------------ Diameter --------------- <br /> � Number ------------- -- Roc Filled Yes E] No .❑ <br /> Water Table Depth -------------- "`=,.-Rock Size -- --------------- i <br /> F -----Foundation ----------- ------ Prop. Line ---------------------- <br /> A/ <br /> ---.------------- . <br /> Distance to nearest: Well .__________________________�___.__ - ---- <br /> REPAIR/ADDITION(Prev, Sanitation Permit s# _...---- �-d-----------`------------- Date ��I1 ----------------) <br /> Septic Tank (Specify Requirements) _______ _________ ------ w -- -- --------- <br /> Disposal Field (Specify Requirements) c - ------------- ------- _� ------- - -------- <br /> _ ` f <br /> ------------------------ <br /> - <br /> ----------------------------------------------------------------- --------4: -------------------------------------------------------- <br /> T -------------- i - <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 San 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 become subject to Workman's Compensation laws of California." <br /> I <br /> Signed ----------------------------- ------ - - -----------------------------------------------Owner <br /> B , 'Titley r• --------------------------- ----------- <br /> Y ----------------- --t-[�----- - - --------------- <br /> - <br /> (If oche an owner) <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---=--- ---------------- ------1------------------------- DATE <br /> BUILDINGPERMIT ISSUED --- -------------------- - --------------------------------------- --------------------= -------------DATE ------------- -------------------------- <br /> ADDITIONAL�COMMENTS ----- -- - -- - -C-- --------C-c-s-_-r-N--�--.----�---------- -----`-�-�----------------- <br /> ------------------------------------- <br /> -- - --� -- ----- <br /> ---------------------------------------- - ----- - -------------------------- - - ------- <br /> --- ------------------------------------ ---------- - --------------------------- -------------------------- <br /> 4 Final Inspection by -- --------------------------------------------------------------------------Date ----- - --- ---- <br /> SAN <br /> --SANJOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M ,� <br />