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FOR (OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- (Complete in Triplicate) Permit No. ________�_ <br /> ------------ ---------- ------------------------------ <br /> _________________________________________________________11��\D This Permit Expires 1 Year From Date Issued Date Issued _-X/F-.�f <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 Orddiin�ance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION a 25-------- �.`-�' Ilu-------------------------------- TRACT <br /> Owner's Name ----- -- k--------- ----------------------•---- ------------------- <br /> - ---------------Phone ------------------------------------ <br /> Address ------------ O-7--S-----V-- --- Ci � ----------------------------------------- <br /> Contractor's Name --------- _License # {� � — Phone ------------------------- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other------------------------------------------ <br /> Number of living units:-------1__- Number of bedrooms .3------Garbage Grinder _________ Lot Size _________ ____ ____ _____________________ <br /> Water Supply: Public 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,) 0 <br /> PACKAGE TREATMENT { ] SEPTIC TANK f ] Size-----------------------------.____------------- Liquid Depth -------------------- ----- V <br /> Capacity ------------------- Type -------------------- Material-------- __ No. Compartments ....................... Ent <br /> Distance to nearest: Well _________________________------____Foundation ---------------------- Prop. Line -__-____--..._---_--_- <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 ........................ <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# ___________________________________________� te ..-------------------------------- <br /> Septic Tank (Specify Requirements) -----------------------------------------------ti ----- R--�-------------------- ---------------------- ----------- . <br /> Disposal Field (Specify Requirements) -------------- � --�--GQ _ a: i� <br /> a - - --------- --`--- <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." > <br /> Signed ------------ - - ---- ----- ner <br /> By ------- 9 - - ----- --------------- -- Title ---r�✓te,,Zo ll--- <br /> ------------------------------ <br /> (If other than owner) <br /> FOR DEIPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY _ __ s�22.__ ____ _ _ ' <br /> -- -------------------- -------------------------------- DATE --�------------ <br /> BUILDINGPERMIT ISSUED ------------------------------------------- -------------------------------------------- --------------DATE ------------- -----------------•--------.- <br /> ADDITIONALCOMMENTS ------------------------------------------ ------------------------------ ----------------------------------------------- --------------- ----------------- <br /> ---------­------------------ <br /> --------------------------------------------- ------------------ ------ --------------------------- --------------------------------------------------------•-------------------------------------------- ----------- <br /> ----------------------------------------- ----- <br /> ------------------------------------------------------- --------------------------- --------------- ------ ------- -------------------- -- ----------------------------- ---- <br /> --------------------- --------- -------------------------------------- -------------------------------------- <br /> FinalInspection by f-- -- - ------------ --------------------- ---------------------------------------------------Date ` j ---��----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H`.'9 1-'68 Rev. 5M <br />