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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - - --------------•----._--------------- <br /> Permit No: <br /> (Complete in Triplicate) <br /> Date Issued ---F-7.(7L <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 /> JOB ADDRESS/LOCATION < ---------- ----------CENSUS TRACT _.j --------------.. <br /> Owner's Name -- if�---- /' ^"'t - ----------------------- --- ---------------...Phone ---------------- ................... <br /> gni <br /> Address ---------------------` + A. <br /> `r'l1 - City n <br /> Contractor's Name --1 a 'Y - --------------------------------------------------------------.License # ------------------------ Phone ------------ -------_------ <br /> Installation will serve: Residence IF Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units:---I------- Number of bedrooms _%3-------Garbage Grinder ------------ Lot Size -- <br /> ----------------------- <br /> Water Supply: Public System and name ------------•------------------------------------------------------ ----------------------------------- ------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom A 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�Aublicc/sewer is available within 200 feet,) �, <br /> PACKAGE TREATMENT [ ] SEPTIC TANK-4 Size_,*_-t_/__-t_/__1 .___'1}'.__`�------------ Liquid Depth �"t --------------- <br /> Capacity _f 00----- Type -------------------- MaterialZVI' --------- No. Compartments .............. 1`l <br /> Distance to nearest: Well --_ f__________ _____-_-.._Foundation ---------------------- Prop. Line _- ------------------ <br /> LEACHING <br /> -----_..._.--. .LEACHING LINE JkJ No. of Lines --------3------------- Length of each line---R-0------------------- Total Length )LY0 <br /> 'D' Boxy Type _ �[ ____..Depth Filter Material ___--._. <br /> 5.-- T e Filter Material _�:--- -'- - <br /> Distance to nearest: Well ---&ro_`--_--.-_.__. Foundation _�v _______-____ Property Line .................. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- 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 /> DisposalField (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 becorpp subject to�Work an's Compensation laws of California." <br /> Signed - d---"--- l-__-_..��� _=------------------------------------ Owner <br /> BY ------------ ----------------- --------------------------------------------------------------- -------- Title ----_----------------------------------------------------------------- <br /> (If other than owner) <br /> FOR. DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - ----------------------------------- ----------------- DATE P-7_377A!n------------_----- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------- ---------------------------------------------------------------------------------------------=----- --------------------- <br /> ---------- <br /> -------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------- <br /> -------------------------------------------------------------- ------------ -- -- --- <br /> ------- ---- --- ------- ----- - <br /> - - - - - - - --- - - - --- <br /> ------------------------------- ---------- ---- - - -- ----- --- - - -- <br /> Final Inspection by: . '11 !_ ...Date '. / Z <br /> SAN JOAQUIN LOCAL HEA4.TH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />