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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 9 <br /> -------fl <br /> AM <br /> (Complete in Triplicate) Permit No. = _. / <br /> 'j Date Issued <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 <br /> in complia a with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO — ------ -- --------- ----- - ----- --------------- -----------CENSUS TRACT <br /> Owner's Name .----------- --- �^ -- - - -- ------------------------------- Phone 3 _/T7 ----- <br /> Address ---=-G..---------_f- --- - City - = <br /> --- ---- -- --- - - -Contractor's Name ----- ------ ____-__________o._____ 0-- -------------------------------License # �tIJ_______ Phone <br /> Installation will serve: Residence VApartment House❑ Cqmmercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------------------- i <br /> Number of living units:------ Number of bedrooms ---3....Garbd a rGr' d r L Size _n_x-- --� <br /> --------------- <br /> -Water Supply: Public System and-name ---------------------- ------- ---.4- ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay j] 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size--------------- ------------------ ------------ Liquid Depth -__-______--..__-_-_--__- 0 <br /> Capacity -------------------- Type -------------------- Material---------- ----------- No, Compartments --.................... <br /> Distance to nearest: Well ____._-____-_____________________Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ______________________ Length`of each 1ine---------------------------- Total Length ---------------------------- <br /> 'D' Box ___________ Type Filter Material ____________________Depth Filter Material -------------------------------------------- <br /> Distance <br /> -__________________._-__-------_- _--._-._Distance to nearest: Well ______________________ Foundation-__-._-__-____-_-___- Property Line ........................ <br /> SEEPAGE PIT [ ] Depth ------------ Diameter-_ ________________ Number ---t.._:_:____,_--__-.--__,y_ Rock Filled Yes `'❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br />` Distance to nearest: Well -----------------------------------.....Foundation -------------------- Prop. Line ----__--•_---.--.----_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _-_____ ------------------------------------ Date ________________________________) <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------------------------------_.------------------------------- <br /> Disposal Field (Specify Requirements) ---------------------------------------------- -- --------------------- ---------- <br /> - y --- --- :. ------------=------------------------ <br /> --- --- -- -- ---�- - - - - - <br /> - -- -- --- _ ------------------------------------------------ _xk-x.�o <br /> ------ ------ -------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 /> "1 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 ------------------------------ -- -- Owner <br /> ------------------- ------ <br /> BY -------------- --G---- -- _ ------- ------------------------ -Title ----- <br /> --------------------------------------------------- <br /> (If other n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------E'-A...-- 14n _ --------------------------------------------- DATE ------- ------------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE --------- -------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------ <br /> -- ---- ----- - -- <br /> ----------- ----------------------------------------------------------- --------------------------- - ------------------------------------------------------------- <br /> --------------------------- <br /> ----------------------------- <br /> _. <br /> - <br /> J <br /> Final Inspection b Date ___._._____ - .� <br /> ------ - - -- - ---------- --- - <br /> PY - ----------- --- ---�1 <br /> SAN OAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />