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{ FOR OFFICE USE: APPLICATION FOR "SANITATION PERMIT <br /> ------------ Permit No. `Xi_:� <br /> k (Complete in Triplicate) ` <br /> .......... -- --- -- - . <br />` This Permit Expires 1 Year-From Date Issued Date Issued --Z- - � <br /> ---------- --- <br /> Application is hereby Wade`to'the San .Ioaquin 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. 547,66d existing Rules and Regulations: <br /> r-- , • •_ -- <br /> JOB ADDRESS/LOCATIONU��4re..di----- -----'----------=---------CENSUS TRACT --------------------- <br /> 9 <br /> Owner's Name ----- ------------------------------------=-�-----------------Phone ------------------------------------ <br /> V <br /> Address ----- t------------- _ ------------------------- City ._,S 5F '---'-_k------------------------------------•----- --- - <br /> r <br /> t <br /> r Contractor's Name __.��__ ____._ _______ License # /_�_.���- -� Phone <br /> ----------------------------------- - <br /> Installation will serve: ' Residence [ partment House❑ Commercial :❑Trailer Court 0 <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units---------- Number of drooms ,_______Garbage Grinder.___ Lot Size _- -1 ------------- <br /> �_ - -----------------------------------------------Private ❑ <br /> Water Supply.; Public System and name ______ _____________ ____________ _ ____ _______________ <br /> a <br /> Character of soil to a depth of-.3 feet: Sand❑ SI ❑ Clay ❑ --Peat [] Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe il! MaterialJ_ If yes, type ______--------------------- <br /> (Plot plan, showing size of Iot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> r t <br /> NEW INSTALLATION: (No se ptic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[" Size----_ s.tC. __------------- #-- Liquid Depth -- %2_______.____. <br />' u Capa ity - -- - : :__-,-- Type - i_� _ j-Material-- -- sti_N,r�u% o. Compartments __ <br /> Distance to nearest: Well ____.__..r-1 _Foundation ___ ............ Prop. Line <br /> LEACHING LINE h/ No. of Lines __47n---------------- Length of each line__. _ - Total Length <br /> -__ Q-- <br /> ���.-s-______ <br /> Type Filter Material ' ______ � -f�________________________._Depth Filter Material _ <br /> Distance nearest:-Well-____________________ __ Foundation __.__�� -_ _ -Property-Line ________......_.__._.___ <br /> SEEPAGE'PIT [ Dept �------------ Diameter _ __`�_-. Number ______�-1_-___-i____ Rock Filled Yes ( No ] <br /> Depth � <br /> Watei jciI------------------------------ble Depth -------�a Rock Size ---,f1 = --------- <br /> Distanc :to nearest: Well ----------- "_------------Foundation ------ Prop. Line'.- _...__=.. <br /> REPAIR/ADDITION(Prev. Sanitation;Permit# _________________________________ <br /> - Date ---------------------•-- --------- <br /> Septic Tank (Specify Requirements) ='---------------------------- ``= .F ^---------------.----•--------------------------- •:yh <br /> _. <br /> Disposal Field (Specify Requirements) ----------- --------------------------=--------- <br /> -------------------} --- <br /> - --= ---------------------------- ---------------------- <br /> , V -- ------------------------ <br /> \ -------------------=--------------------- ------------------------------------------------ <br /> (Draw existing and required addition on reverse side) ",f,,j <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.perm f'`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 ---------------4th:5an <br /> --------------------- ------------- -- ------- --------------------- <br /> ------------------ Owner <br /> BY -----'---- ----------V`-' ` ----------------- <br /> ---- <br /> ------- <br /> - Title = i <br /> --- ---- ---------(If owner) <br /> D TMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- ---- ------------------------------- -------------DATE ----- ------------- <br /> BUILDING PERMIT ISSUED --------- --- ------ --- - -- -- - -------- - -------------------------------------= ---------- --DATE ----------------------- ------------ <br /> ADDITIONAL COMMENTS ___ _ __ <br /> 3. f - ---- ------------------------------------------------------- -------- =--------------------------------------------------- <br /> A_. e <br /> -- - ---------------------- --- - ----- -- ---- ------- - -------------------------------------------------------------------------------------------- -------- -- <br /> Final Inspection by: --------- ------ - ---- -- -- -- ------------------------------- ------------------ --------------Date __�=�G'f� f <br /> 11IN LOCAL HEALT--biSTRICT :-r <br />