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FOR OFFICE USE: <br />---------=-------- -- -t <br />---------------------------- ----------------------- <br />APPLICATION FOR SANITATION PERMIT <br />(Complete in Triplicate) <br />This Permit Expires 1 Year From Date Issued <br />Permit No: 6____ <br />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 />ly JOB ADDRESS/LOCATION . ��f� { ---- -- _Cfi�-------------------- -CENSUS TRACT -_--- -----------•---- <br />Owner's Name-----�-- -------Phone ------ <br />Address` �� !2 <br />------------------ . City' --------- --------------------------- <br />Contractor's Name _____ License # _�e 3_R -y Phone ________________________--_ <br />Installation will serve: Residence Apartment House Commercial :❑Trailer Court ❑ <br />Motel ❑ Other ---------------/-------------------------------- <br />Number of living units: ------ f____ Number of bedrooms ____`4__Garbage Grinder ------------ Lot Size _.__ ------- <br />Water Supply: Public System and name---------------------------------•----------------------------------------------------------------------------Private [jam <br />Character of soil -to -a- depth of 3 -feet:- Sand'❑ Sift E] Clay [ ] Peat ❑ SandyLoam-❑'Clay Loam o"'""� ' <br />Hardpan ❑ Adobe `❑ Fill Material ___.____ If yes, type __________ _____ <br />(PI'ot plan,—showing-size of lot, location of system in relation to wells, -buildings, etc. must be placed on reverse sicle.l <br />NEW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is available within 200 feet) <br />PACKAGE TREATMENT (] SEPTIC �TANK'[7 Size:`5-----t�---r!- Q-------X-----------------Liquid Depth ----V---- �---------- <br />Capacity, --®- ------ Type �=ire''-- Material____ No. Compartments ___--.____.:.... <br />Distance to nearest: Well -------- .5"�__---------------- _____Foundation ----- td__1--------- Prop. Line <br />LEACHING LINE [ g�No: of Lines --------- __.___ Length of each line ---------&.0 Total Length --------------------------- <br />'D" Box <br />____.--_-_---__--__..D''Box ______:_ Type Filter Material ______..h -__Depth Filter Material __ _________________-_____.._ <br />Distance to nearest: Well ______§5to�__r______ Foundation ----- 1_0 _!________ Property Line-S____�____�._..__ <br />SEEPAGE PIT [ Depth ------ x.47___ Diameter __T___r--- Number ___._.__._._�_____.__ Rock Filled Yes No i❑ <br />Water Table Depth-----------------`5� /-----------•----• f 3 <br />Rock Size a ------=Y-.---.---- <br />i r <br />.S'/. ; <br />Distance to nearest: Well _____________�3©_____________------ Foundation �0_______.____ Prop. Line ---------------------- <br />REPAIR/ADDITION <br />-_______-_________ __REPAIR/ADDITION (Prev. Sanitation Permit #____________________________________________ Date _________________________-______-_) f <br />SepticTank (Specify Requirements) - - - - - - - -----------------=------------------------------------------------------------------------------- - -- - -- --------------------------- <br />Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------- <br />6 <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 />BY -------- ---------------------------------- i .,/ =_ Title ---- .Llr`�= "`....... ---------------------------------- <br />V f <br />.(If other than own j :yam <br />OR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY _.__.____. DATE __ //`.� 7' -7� <br />----7 ---- <br />BUILDING PERMIT ISSUED---------------------------------------------------------------------------------=------------------------DATE <br />ADDITIONAL COMMENTS ----- <br />-------------------------------- <br />---------------------------------------------- <br />------------------------------------------- �-2 s__ J�� rf �� --------- <br />----- ---------- ------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------- <br />-------------------------------- - <br />Final Inspection by:. ---------------------------------------------------------- Date .fes= ----------- -------- <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />E. H. 9 ­_�_ 1-'68 Rev. 5M-_- <br />