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FOR OFFICE USE, <br /> 11 . 1 -j Z? _1;_1 - APPLICATION FOR SANITATION PERMIT <br /> i-------b5,--------------- Per <br /> 71 ip (Complete in Triplicate) mit No.. <br /> ---------7------------I This Permit Expires ] Year From Date Issued Date Issued <br /> Application is hereby made to'the Son 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 /> CENSUS TRACT --------------------------- <br /> JOB ADDRESS/LOC TIPN _�------- - ------------------- ------------- <br /> � _>--------------- - <br /> A- <br /> Owner's Name --- -- ----- <br /> ----------------- --- - <br /> WT I _x ---_---------- -------Phone--------------------------------- <br /> /;,h _. city ----------------------------------------------------------------- ---------- <br /> Address ------------------- <br /> Contractor's Name <br /> ---------- ---------License # h o n e�_ 4�7 <br /> ---------------------License.. <br /> Installation will serve: <br /> Residence E].Apartment House 119- bmmerclaf OTrailemr Court El <br /> Motel f-1 Other--------------------------------------------- <br /> Number of living units:­v� ---- Number of -------- <br /> ecIrooms- ----Garbpge Gr%e, ---- Lot Size ----- <br /> - ------------------- <br /> Water Supply. Public System and name --- ------ -------- --------- <br /> ---------------------- <br /> Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'o Silt El Clay El Peat F] Sandy Loom -0 Clay-Loam <br /> Hardpan E] Aclobe,E3­177eMaterial 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,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK. ] Size------------------------------------------------ Liquid Depth ------------------------- (A) <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ----------------- <br /> Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line _11------------------- <br /> LEACHING LINE, No. of.Lines ------------------------ Length of each line---_--____.______.__._____ Total Length ............................ <br /> 'D' Box _';------- -- Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distance to nearest:.Well ------------------------ Foundation ------------------------ Property Line --------------------- <br /> SEEPAGE PIT Depth -------------------- Diameter ---------I------ Number _-___---°+-______.____-____-------------------- Rock Filled Yes 'F <br /> No <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------•------ <br /> Distance <br /> ---------------------__------ <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------- <br /> ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ---------------------------------_} <br /> Septic Tank (Specify Require-ments) --------------------------------- ------------------------------ --------- <br /> ---------------- ------------------------------------------------------ <br /> Di Dosal Field (Specify Requirements) ------�__,X,11. <br /> - -- -------- <br /> e' <br /> ---------- <br /> --- ......... <br /> ---- ------- ------------4- <br /> ---------------------------- <br /> --------- -- -------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------I-------------- <br /> (Draw existing and required addition on reverse side) I <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 ltegualations 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 <br /> - ------ ----------- ------- Title <br /> -------------------------- - -- <br /> (if of l er'howner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE ------- <br /> ------------------------------------------- <br /> BUILDING PERMIT ISSUED <br /> /------------------------------------------------- ----------_-DATE ------- ----------------------------------- <br /> ADDITIONAL COMMENTS <br /> ----------------- ------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- <br /> - ------------------------------------ -------- ---------- <br /> ------------------------------------------------------------------- <br /> Final Inspection by: ------- --- --- ----------------------Date -- --------1_�7------------6- <br /> _2� cf <br /> ----- ------ --------------------------- ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-68 Rev. 5M <br />