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FOR OFFICE USE: <br /> { APPLICATION FOR SANITATION PERMIT <br /> ----------------1_,_30---------------------------- <br /> (Complete in Triplicate) Permit No. <br /> ---------=---------- ------- <br /> ---------------------- <br /> Date Issued ____%1_�3!' <br /> ------------------ Ll.___---- --- _------------ 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 .--____% _5, -- <br /> - _-1 /_ _ % --------- -------CENSUS TRACT -�,----.-------�•-,,i. <br /> Phone --- ) <br /> Owner's NameYl y --------------------------- - j -�' <br /> AddressQ W------- ------ -a <br /> c/ �r - • --•-----•--. City �Iv?? = - Y <br /> Contractor's Name __________________-__-___--_._____.License _� Phone _.__ <br /> Installation will serve: Residence 7]Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other ---- -------------------- <br /> ------------ <br /> Number of living units:------------ Number of bedrooms _.....Garbage Grinder ________ Lot Size __________________________________ ....... <br /> Water Supply: Public System and name ---------------------------------•----------------------------•----------------------•------------------------_Privatelk <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,) CA <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size___- -__ qDepth <br /> ,Q_ <br /> Capacity %. _____ Type .���-- Material _C - No. Compartments _________________ <br /> Distance to nearest: Well ____t U-_---_.__•_--___-____-Foundation _l d_ --------- Prop. Line .. ..... <br /> LEACHING LINE [ ] No. of Lines ----- ?------------- Length of each line-----70-------------- Total Length .. <br /> `i <br /> 'D' Box __________ Type Filter Material _ .- -_._Depth Filter Material _-%1 ------I....................... <br /> Distance to nearest: Well ----!4�P---------- Foundation __ _ ---------- Property Line4�................... <br /> SEEPAGE PIT [ j Depth ._,---_-__ ------ Diameter _______________ Number ---------------------------- Rock Filled Yes '❑ No i❑ <br /> Water'7ei6le 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 /> •-- ----- - ----- ------- -------- ------ --------- ------------ ----- ------------ -------- ------ -- --- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 -- ------- --- - --- --------- ---------5---- ---- Owner <br /> BY ------ --- --- ---- ---- - <br /> ---------- - -------- ------------------------------- Title ------- ---------------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _________________ y_-_ _. DATE _--._ _—_l _' _________._ <br /> ------------------------------------------- <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------------------------ ---------------------------DATE ----------------------------------------- <br /> ADDITIONALCOMMENTS --------- -------------------------------------------------------------------------------------------- ------------=--------------------------- <br /> - ------------------------------------------------------------ -'---------------------------------------------------- --------- ----------------------------------------- --------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- <br /> ------------------------------------------- -- - ---------- - <br /> Final Inspection b ------------------------------------------------- ---------------------Date ---_Zr :'--------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />