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' . J <br /> FOR OFFICE USE: <br /> 3 � APPLICATION FOR SANITATION PERMIT <br /> ----------------- ----------------------- ----------- (Complete in Triplicate} Permit No: <br /> ------------ Da <br /> te Issued <br /> -------------A _____________ This Permit Expires ] Year From.Date Issued -_—fd��'� <br /> f <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 an existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION - _---R_7 D4 -------- ii'�- ----- � CENSUS TRACT --------------------- -- <br /> Owner's Names / � -,-�-----------------------•------------------------------�---*--=_---------------------Phone -------------------------------•---- <br /> Addressrj ------°��'f------- � ���-------------------------- ------------ City ------------------------------- ----------------------- <br /> Contractor's Name ` "/w L_' r�_--S4?-e/---------- -----.License # - -lT -- Phone <br /> Installation will serve: ResidenceVApartment House❑ Commercial [-]Trailer Court ,❑ <br /> I Motel ❑Other ---------- --------------------------------- <br /> Number of living units:. - __ Number of bedrooms --_ g <br /> Garbo e Grinder ____-------- Lot Size --------------- <br /> Water Supply Public System and name ------------- --- ------ -------------------- ---•----------Pri <br /> vate <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay F1Peat F1Sandy Loam ❑ Clay Loam <br /> Hardpan FI Fill Material ------------ If yes, type ---------------------------- <br /> .� t <br /> (PI'ot 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 availablewithin 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC,TANKY�'' <br /> Size-- -------- Liquid Depth ----�--_--_--_-._---. O <br /> Capacity f r - - ,-_ Type +'' _ TMaterial a 2G_6_____--No! Compartments ------- <br /> Distance <br /> --_--. .. .... (V_' <br /> LEACHING LINE Not of Lmesnear Well <br /> --- :-�__-__________________F�dation _��____------- Prop. Line/_�__- _, :.:�1 <br /> ------ -. -- Length of each line-- :4-______9�-_----- Total Length <br /> .......... <br /> LEACHING <br /> 'D' Box ----/----- Type Filter Material J jr'1 Depth Filter Material --- --------------."_______ _ _ _____ <br /> Distance to nearest: Well ----------- Fouridation _-_--_-=-_:---.Property Liner--- <br /> SEEPAGE PIT [ ] Depth --------- ---------- Diameter ---------------- Number --------------.------------. Rock Filled Yes ❑ No <br /> ' r <br /> WaterTable Depth ------------ ----------------------- --------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------- -.-- <br /> REPAIRJADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---_------------.--._-___---_----_) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------•----------------------------------.----------------------------- <br /> Disposal Field {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 be rine s bled t Wo an's C,om sation laws of California." <br /> Signed - -- -- --- --- ---------------- Owner <br /> By ------------------------------- -- ? --------------- Title <br /> 1 <br /> (if other than owner} <br /> FOR EPLRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = - ------- __ -------- --- ------`------------------------- DATE . r 7 <br /> BUILDINGPERMIT ISSUED ---------------- ------------ --------------------------- --------------------------- -----------DATE .------------------------------------------ <br /> ADDITIONALCOMMENTS ---------------------------------------------•--------------------------------------------- --------------------------------------------------- ------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------ -- -- --- ---------------- ---------------------------- -------------- <br /> - - <br /> -------------------------------------- ---------------------------------------------------------------------------------- -- - ---- --- <br /> - •-- <br /> -- - -------------------- <br /> Final Inspection by- ------------------ ----- -------------------•------------------------ ------Date -- = <br /> SAN JOAQUIN LOCAL HEALTH DI ICT <br /> E. H. 9 1-'66 Rev. 5M <br />