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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT s <br /> ---- --'----------------------------------------------- <br /> Permit No. <br /> --` (�--------------------- (Complete in Triplicate) 7-z- � <br /> Date Issued .. .............. <br /> Z- <br /> -------------------- ----­------------------- 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 /> ------- ---- <br /> YQ 2 ,,' II /V - �4'_t-u_GW CENSUS TRACT -5 `3 l <br /> JOB ADDRESS/LOCATION . Vim- ----- -- -------- <br /> Owner's Name � � -� GZ e- � 1 -- -------Phone ------------------------------------ <br /> ------ <br /> Address - -- y.-� - ----- - - City0,231 -------------------------------------•------ <br /> Contractor's Name` `"'`J-----------------------License #� ------- Phone <br /> Installation will serve: Ream_.@.-..sidenceXApartment House❑ Commercial [-]Trailer Court <br /> Motel ❑Other -------------------------------------------- i <br /> Number of living units:------/----- Number of bedrooms __3------ <br /> --/G-ar�baage Grinder ------------ Lot Size ........... <br /> Water Supply: Public System and name ----Z;__`" - ` "= _•--._._-_-_.-__-_.•_----------------------------------------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.) 1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q <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 /> '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# -------------------------------------------- Date -_.----._-_------------.-.------) <br /> Septic Tank (Specify Requirements) ------------------------- -------- ---------------------------------------------------- / 7--------/ <br /> Disposal Field (Specify Requirements) ------- r- ------------------------------------------------ ....... ` _ 2_X --------- <br /> --------- --------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- <br /> ------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 sub' ct tMrk�m 's Compensation laws of California." <br /> Signed - -z.- -------------------- Owner <br /> ------------------------ <br /> BY ----------------------------------------------------------------------------- ------------------------ Title --- ---------------------------- --------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 131 ---'------------- -------_:-- ----_---_---. DATE 3---------------�_-._7 <br /> -------------------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE -------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------- -------- -------------------- ------------------------------- -- <br /> -- -- ---- <br /> - - --- ------ ---------- ---------------- - --------- -------------------- - ------------------------------ <br /> --------------------------------------------------- - <br /> ------------------------------------ ------- <br /> - - - - - - -- -- -- - <br /> Final Inspection by: ----- - ---------------------------- - ----- ---------- -- -- --Date --_— -` ----- - -------•- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />