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FOR or%FICE USE: APPLICATION FOR SANITATION PERMIT ) <br /> -------------------- Permit No. <br /> (Complete in Triplicate) <br /> -------------------ZA--- --------- q <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued __./.-__2_��� <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. <br /> 5549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC TION . ' mss- ----- -- -- - � ��- _CENSUS TRACT <br /> -------------------------- <br /> -------= - -------------------------------:---------------- -Owner's Name Name ._ _ _..____ _Ph ne <br /> Address ---------- -- --------- ----- - -- - --- ---------------------------------------- Cit Y --- -- <br /> Contractor's Name <br /> _ -- _ __ 2i!_-1---.License # ��5W2 --- Phone <br /> Installation will serve: ~ Residence ErKpartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:________ Number of bedrooms _______Garbage Grinder ------------ Lot Size __- a� "° � ------- <br /> Water Supply: Public System and name -------------------------------------------------------------------- •----------------------Private R-­- <br /> Character <br /> —Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam g <br /> Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes,type ---------------------------- t4 <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,) , <br /> PACKAGE TREATMENT [ I SEPTIC TANI(fk -' �02 XS`� ------------ Liquid Depth -------------------------- <br /> G' <br /> Capacity Type __--__ -----_ Material___._-0? -_ No. Compartments _.__ .... <br /> '_'� `.......... <br /> Distance to nearest: Well ------�.f__©_______________________Foundation --/-Z)------------ Prop. Line <br /> LEACHING LINE [ No. of Lines ----- <br /> -------------- Length of each lin ;_ - -------------- Total Length ---/ �%__.____._.__ <br /> D' Box ---. ---- Type Filter Material s'u`��-�C_li'__Depth Filter Material <br /> ----------- _'_____________ <br /> Distance to nearest: Well ------- Foundation ______ /'4-- Property Line ____ - 1`"2 <br /> `r r. -__ Rock Filled Yes X No 0 <br /> SEEPAGE PIT [� Depth _.�-S.________ Diameter _�______ ____ Number ._.- *�_______� <br /> Water Table Depth -----------?---------------------------------Rock Size p - ----,---------- <br /> Distance to nearest: Well ----I _ _ r __�___ Prop. Line ... --" <br /> L"e_______________________Foundation <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _______---_----------------;---------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------'�-- ------------------------•-------------•"---------------------------.,.-------------------------•- <br /> Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- <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 becoe subject to or an's Compensation laws of California." <br /> Signed ------ -�1 -- ` - --------------------------- Owner <br /> BY ---------------------- -L - -- ----------------- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> TMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- -- ---- ----------- ------------------------------------------------ DATE ----- ? 7---------------.._. <br /> BUILDING PERMIT ISSUED ---------- - ----- ---------------------------------------------------DATE ---------------------------- -------------- <br /> ADDITIONALCOMME TS ---- - --- ---- ----- -------------------------------------------------------------------------------------------------------------------------- <br /> 17_--- z1-------- --/- `s - ----- - ------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------•----- - ---- - ---- --------- -- ------------- ----------------------------------------------- -------------------------•- ---------------- <br /> Final Inspection by: --------- ----- - - -- - - - --------------- ------------------- ---------------Date ------------ <br /> N OAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />