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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) ©°�3 <br /> Permit No. - <br /> --------------------------- ------ <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/LOCATIO /, <br /> _ 9 ,3_, 'S'_.._170�3tl17-_Z- -_ -. - 7_ <br /> CENSUS TRACT J ______________ <br /> Owner's Name -4�- -�--- ��.�-------------------------------------------------------------------------------------------Phone ------------------------------------ <br /> Address ---------- �-----------------------=-------------------------------------------•--. City ----- ------------------------------------------------------------- <br /> Contractor's Name i----------------------------------------.License # ------------------------ Phone ----------------------------- <br /> Installation will serve: Residence;X Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ---------------------------------------- <br /> Number of living units:---,/----- Number of bedrooms _%Y___-_Garbage Grinder . fl_ Lot Sizers__ _________________.... <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 ____________________________ fifi ' <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> N <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) lnt <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth _..____-- .-_.-__----_- <br /> Capacity --- Type ------------------- Material---------------------- No. Compartments ------.__------------- <br /> Distance to nearest: Well _-_-___________-_________________Foundation ---------------------- 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 /> 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 /> Disposal Field (Specify Requirements) -.42JVW <br /> ____ , � .,1 _ -_ _ ._ h,�- _..-.---____-- <br /> ---10140-090'---------------------------------------------------------------------------•---------------------- <br /> r <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 /> "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 subject to Workman's Compensation laws of California." <br /> Signed ---- --------------- -------------------------------------- Owner <br /> BY - -- ------------------------------------- Title ----------------------------- <br /> ( her than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _f,' - DATE _%! <br /> BUILDINGPERMIT ISSUED --------------------------------------------------------------------------- ------------------------------DATE ------------- ----------------- <br /> ADDITIONALCOMMENTS --------- ---------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- ----- - -- <br /> - <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------- - <br /> ---------------------------- -- <br /> , - -------- J <br /> FinalInspection by: ------------------------------------------------------------------------------Date,l�' rf <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />