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FOR OFFICE USE: I r� <br /> APPLICATION FOR SANITATION PERMIT <br /> - ------------------ <br /> \ Permit No. _���- � <br /> (Complete in Triplicate) • - <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 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/LOCATION _- � ------ -_Cti`lle `_'-----------------------------------------_----CENSUS TRACT --------------........... <br /> Owner's Name -----------V------- rcL-Zl_s,. --------------------------------------------------------- -------Phone ------------------------------------ <br /> Address -------------- City . ----------------------------l�-----------------------•-- <br /> Contractor's Name 4- 4' --4-------------------------------------- < I <br /> .J ___.License #,� _1 2Phone _ --_�`----Z� <br /> Installation will serve: Residence [Apartment House,❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other ---------------------------- _------------ <br /> 1-._- Number of edrooms -4_ _.Garbo a <br /> Number of living units:----- _ ,Garbage Gri er��---_ Lot Size _�--_��.--_�„................. <br /> P r- n <br /> Water Supply: Public System and name _ lz�__I__ ............r_} _e------_-. '2--------------- ---------------------__..____Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ <br /> Hardpan ❑ Adobe ill Material/4_'`°__- If yes,type ------------------_-___-_- <br /> (Pl'ot 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� Size_.--__ _ <br /> ) � 1 'i�,X--�--X-l�-r,-t-------------- Liquid Depth ---- /- --•-•------ <br /> Capacity 1__\A2 Type -+f- Material__�oZ- No. Compartments -_ _ <br /> l r_ <br /> Distance to nearest: Well ----------""E'-_—----...----Foundation ------I-a-,------- Prop. Line ._............... ”) <br /> LEACHING LINE (0 ,,No. of Lines J. Length of each line_-_ -Q6--� '� .. <br /> /' - Len 1 ' --- - ------ Total Length --�--- -----••---•----•- <br /> ---------------- - - - <br /> 'D' Box Type Filter Material _ =-------.Depth Filter Material ---/J .......................... <br /> Distance to nearest: Well _---- _ �'__ .-__ __ Property Line .1.-/............... .� <br /> -�'._-_. Foundation ---___. <br /> :i <br /> SEEPAGE PIT Depth _.-.--_.- Diameter-36----- Number ---_l--------------_--- Rock Filled Yes [B---No ❑ <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) --------------------------------------- -------------------------- <br /> ---•------------- ----------------------- ----,._----------------•-•-------- <br /> - <br /> DisposalField (Specify Requirements) -•--------------------•----------------------------------------------------------------------------------------------- -------------- <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 subject to Workman's Compensation laws of California." <br /> Signed --------------- --------- --,------------------------------------------------------ Owner <br /> -- - ------------------------------------------- Title �s/2 --------------------- ------------------------ <br /> (If r than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -__�__> _�___..-- - __ - DATE _.._ �__ .1�--_..rd_ ..___ <br /> !K --------------------------------------------------- <br /> BUILDING PERMIT ISSUED ------ ------------------- ! ---------------------------------------------- ------- -----DATE -------------- <br /> ADDITIONAL COMMENTS _.____.-__ -_-__ .-__-__-_ _ <br /> ----- ----- -----• f T--------- �3�i' d -- --- - ----------------------------------- ---------------------------------- <br /> ------ <br /> ----- --------- <br /> ------------------------------------------------ <br /> -------- --- ----------------------- ---------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- - -- ----- -------------------------- ------------ ----- ---------=------- <br /> Final Inspection by: -------------------------------------------------------------- <br /> - -------- - Date ----- -` <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />