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t <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> �. ._ Permit No. 3_ 3 <br /> (Complete in Triplicate) <br /> • Date Issued _�."�_�'.�",7 ' <br />__-_-_-_----_---__----__--------------------------i This Permit Expires 1 Year From 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 No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA N .- -_-- ®_Is►�� e- -----------------CENSUS TRACT . ................... <br /> -- --- �----y- ---- - - __-_ *� � <br /> Owner's Name ____ <br /> - - ---------- <br /> _ P <br /> City -- <br /> Address ----- 1 �- <br /> ----------- - - <br /> Contractor's Name ________ ------------------------------------------------------------------------------------------------------------------ ----..License # ------------------------ hone ------------------ ---------- <br /> 'Installation will serve: ResidenceApartment House,❑ Commercial❑Trailer Court ❑ <br /> Mot ❑.Other - <br /> Number of living units:___________ Number of badrooms j-----Garbage Grinder Lot Size ................._-------..---------------- <br /> Water Supply: Public System and name ------- W _--------------------------------------- Private E]p <br /> Character of soil to a depth of 3 feet: ' Sand' Silt E] Clay 'Clay Peat❑ Sandy Loam ❑ Clay Loam [-IHardpan ❑ Adobe Q FiII Materia) ------------ 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.) 0 <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 -------------------- Material---------------------- No. Compartments -------- -- -------- <br /> Distance to nearest: Well ._.-__---.--_-_-------------------Foundation ------------------ -- Prop. Line --,----.--.__--------- <br /> LEACHING LINE [ ] No. of Lines ---------------- Length of each line___.___.__________.______ Total Length ........... ................ <br /> ------ <br /> .n '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 i❑ <br /> Water Table Depth ------------------------------ <br /> ------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ---------------------------------- -----Foundation -------------- ---- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----..---..-----._.---------------) <br /> Septic Tank (Specify Requirements) -------------------------------------------------------------- ---------------•=---------------------•--- ----- ------------------------ <br /> Dispo F' d (Specify Req. 'rements) .-..-.-.-- � ----------- - --"----------- <br /> -- - ---------------------- <br /> ------------------------------------------------------=------------------------ <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 becom bject to Wo.rkm 's Compensation laws of California." <br /> Signed .�r7 Owner r <br /> ------------------------------------------------ Title --------------- ------------------------------------------------ ------- <br /> (If other than owner) <br /> It FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ._ ...._.----.--- DATE --------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------------------- <br /> ••------ -------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --------------------------------------------------------- <br /> ---------------------------------------------------------- <br /> ----------------- <br /> =----- <br /> ---•------ ----------- <br /> ------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------- ---------- --- --- -------- ---------------­----------- <br /> ---------- <br /> - <br /> -------- <br /> --------- -------------------- - ---- - ---------------------------------------- <br /> ------------- <br /> ---------------------------------- --------------------`------ ----------------------- --------- ----- -------------- <br /> ----------------------------- ------ <br /> - <br /> Final Inspection b ------------- -- -------- --------------------------------Date ---------------- <br /> SAN <br /> ----- - <br /> SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />