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FOR OFFICE USE: APPLICATION FOR SANITATION NITATION PERMIT <br /> - i` <br /> i (Complete in Triplicate) Permit No. __7-- -____._... <br /> --------- ----------------------------------------------- \� <br /> _ \ ___ <br /> -__--____--__--_---_ _ _ _ <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 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 /> �1 � - ----------------CENSUS TRACT ---5`��---••---------- <br /> JOB ADDRESS/LOC/ATION .__7.73_r ""L ------. <br /> Owner's Name - 'iG..-------- --------------------------------------------------------------- -------------------Phone 34 f--l-2'-'---73------ <br /> Address --y7__67 f-------s --------------------- --------------------------- City ---------------------------------------------------------------------------- <br /> Contractor's Name --------o1oft►' +------------------------------------------------------........License # ---------.-------------- Phone -------- ......--------------- <br /> Installation will serve: Residence q Apartment House f-] Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:___________ Number of bedrooms ------------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 rel do o wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit p d if public sewer is available within 200 feet,) N <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] ize-----------------------------------.------------ Liquid Depth ... ---------------------- <br /> Capacity __ Type ____ ----------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well ___ ____________________________Foundation ---------------------- Prop. Line .__.................... <br /> LEACHING LINE [ ] No. of Lines ----------------------- ength of each line---------------------------- Total Length -----------__............... <br /> 'D' Box ___________ Type Fit Material ____________________Depth Filter Material ___-_________.._____._._....__.--.-_---___-_ <br /> Distance to n est: ________________________ Foundation ------------------------ Property Line ----------_------------ <br /> SEEPAGE <br /> ____----- _-_____-_-_-.SEEPAGE PIT [ ] Depth ---------- __ ____ ameter ________-___- Number ---------------------------- Rock Filled Yes '❑ No i❑ <br /> WaterTable epth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to ne rest: ell _______________________-_-__________-_Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Per it ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ----------------------------------------------- ------- <br /> Disposal Field (Specify Requirements) _______At _____ --- -----� '" '"� <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 becomsubject to Wor an's Compensation laws of California." <br /> Signed --- -Q.C�--1.------ C1'44e* - ------------------------------------- Owner <br /> BY ----------------- -------------------------------------------------------------------------- Title ------ ---------------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- '`p . ----------- -------------------------------------------------- DATE ------------------ <br /> BUILDINGPERMIT ISSUED ------------------------ -------------------------------------------------------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------•-- <br /> ------------------------ <br /> ,°t--- ------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------- r�?"�`*i�+"'' W----------------------------------------- ------------------------------------- <br /> FinalInspection by: ------------------------�`------------------ --------------------------------------Date -`- -------- --------------------- <br /> SAN JOAQUINc LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />