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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------------- <br /> -------------- (Complete in Triplicate) Permit No. .. <br /> This Permit Expires 1 Year From Date Issued Date Issued _. ..7/2 F .. <br /> -- <br /> ------------------------------------------------------- <br /> Application is hereby made to the San Joaquin`Local Health District for a per 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 /> j / .. <br /> JOB ADDRESS/LOCATIONl _________CENSUS TRACT __________________________ <br /> Owner's Name .--------D4-,i_L -------- ------------------------------------------------------- ---- -Phone _----------- <br /> Address -------------------------?Y/w------ —------------------------------------. City ----5wc.4-X� -------------- --------------------------------- <br /> Contractor's Name --.._ _ `__ e....... t�_ .n t.�� -------License # ___f.l1y�7d Phone ?'e -------- <br /> ,Installation will serve: Residence[Apartment House❑ Commercial:❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-----/----- Number of bedrooms ____d?,.Garbage Grinder ------------ Lot Size /ArITX��v................ <br /> Water Supply: Public System and name -------------•---_-_ ----•-------------------------........... -----------------------------------------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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' C <br /> PACKAGE TREATMENT [ ] SEPTICTANK Size--------------------------__----- -_-. .__-.-.- Liquid Depth -.__._.____._...-__...___ <br /> Capacity _/_;CIU__,.- Type Material__-_ `�r�Ctrti CNo. Compartments _�-.........:.... `n <br /> Distance to nearest: Well -----C ...�.......Foundation e)____-_.-__ Prop. Line ________ <br /> LEACHING LINE [ J 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 i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to neargst: Well -------_ ------ ------ ---__--Foundation ------------- ------ Prop. Line ...._.__.............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___-___-_._-.__-------Z'------------------ Date ____.._---___-----_____-._-______- <br /> Septic Tank (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 become sub'ect to Workm 's Compensation laws of California." <br /> Signed --- -- --- --------- --_-----------------------_ Owner <br /> --------------------------------- <br /> BY ----- L- -- ------ ----------- - ---------------------- <br /> Title __.._. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------'--- -------------- -------------------------------------------------------------------- DATE ..!;! 1-1 <br /> ----------- <br /> BUILDING PERMIT ISSUED . -- -- -- ------- _ -----------------------DATE ---------­--- ---------------------- <br /> ADDITIONAL <br /> ----- ---- ---- ----- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------'------------------------------------------------------------- ----------------------- <br /> --------- ------------------------------------------------------I-------------------------------------------------------- ----------------- <br /> --- <br /> } ----- - <br /> -- --- - -- -- -- --=-- - --- -- ----- ----- --------- --------- <br /> ;.�-�- '7 <br /> FinalInspection by: --- `" -`"'�'--- -- -•- ------ •-------------------•-----•---._.•-_..---------------------------------------.Date --------------------------------._.-•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />