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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------I---------------------------------------------- <br /> (Complete in Triplicate) Permit No. <br /> ----------- -----4-LI---I----------------------- <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 - 1 `` 4 C ------------------------ ------------------CENSUS TRACT --------------_--------- <br /> Owner's Name ------ iz ` --------------- -------------- ------------- --=- --------- --Phone <br /> Address --------- --------------- City Lis .----------------------------------------------- <br /> G <br /> Contractor's Name /� G.c �, _r_f! 44 <br /> ---_--License # o�- - -�a-1-7__ Phone _3_ •"' .�_•!._��- <br /> Installation will serve: Residence Apartment House,❑ Commercial DTrailer Court i❑ <br /> Motel ❑Other ----------------------------------•--------- <br /> Number of living units:----/------ Number of bedrooms a-----Garbage Grinder ----------- Lot Size ------- -- ----------- <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 /> 01) <br /> l <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> �8 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) J <br /> ` 7 i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-. ------- Liquid Depth ..... . ...... <br /> Capacity -1,20-4------ TypeCompartments ___r <br /> Distance to nearest: Well -------- __________________Foundation ...../_e Prop. Line ____J ______-•___ <br /> LEACHING LINE [ ] No. of Lines -------;2------_-____ Length of each line-------- '-_Q'------------ Total Length -------i_4_c'............ <br /> 'D' Box' _ Type Filter Material _1?�-------Depth Filter Material --- ----------------------------_______ <br /> Distance to nearest: Well _--_--5_-_1C-_____---_ Foundation ------1__�---__--___ Property Line ------- ........... ' <br /> SEEPAGE PIT [(] Depth ------- Diameter Number -----.__- ---------------- Rock Filled Yes No i❑ <br /> Water Table Depth —-- <br /> Rock Size <br /> Distance to nearest: Well -----_fid___________________________Foundation -----./(�_.------- Prop. Line ___-. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (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 become subject to Workman's Compensation laws of California." <br /> Signed ------------------------------------- ------------------------------------------------------------ Owner <br /> BYl l3 - 1 ------ --------------------------------------------------------- Title - --------------------------------------------------------------------- <br /> (If other than n�ned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ----------- ----------------------------------- -------------- DATE ----7 .......... <br /> BUILDINGPERMIT ISSUED ------------ --------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------- -----------_----- ---------------------------------- ---- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------- ------- <br /> --------------------------------------------------- ------------------------ --------------------- <br /> --------------------------- <br /> Final Inspection b Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />