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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- - -- - --------------------------------------- Permit No. <br /> (Complete in Triplicate) !" " <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 per 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 /> I <br /> JOB ADDRESS/LOCATION .--- - omo--------- ---------------.-CENSUS TRACT ------•----- <br /> Owner's Name -------=-------------E,7Ae' Ci't-----cQ(L-`-t--=------- Phone ------------------------------------ <br /> Address - ------------------16-tt-6-- `LjCJtu-- Sa o--(26 ... City <br /> --------------------------------------------------------------- <br /> Contractor's Name ----------------1' W fl--------------------------------------License # -a- 577-01 Phone g aY gyq-1----•-- <br /> Installation will serve: Residence'fApartment House°❑ Commercial❑Trailer Court ❑ <br /> Motel ❑Other -------------------------- ---------------- <br /> Number of living units:--.-_ __- Number of bedrooms ___3_____Garbage GrinderAb_._ Lot Size _�- � ___ 7_________________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Privatet]— , <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe E—'riill Material ------------ If yes, type ---------------------------- <br /> (Prot 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 f size-------4900----------------------------- Liquid Depth -----�2-------------- _4� <br /> Capacity ,900------- Type ---_ Material_MQ�A__ No. Compartments ----;----...__---- <br /> Distance to nearest. Well ---------§­!�-------------------Foundation ----A�------------Prop. Line ---- --__--_-_ <br /> LEACHING LINE [ ] No. of Lines ....-- .3---_------__ Length of each line------- .Q------------- Total Length _C23K�-_--_-_------ <br /> i9 <br /> 'D' Box .._ Type Filter Material _ ____Depth Filter Material ------ 2.1-__1---------------------------- <br /> 4 - <br /> -.__------------- --- -- <br /> _ _ _. <br /> Distance to nearest: Well .-_______�-------- Foundation ----/_0 Property <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------.-------.---- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ----------------------•--------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION <br /> ________._-__-_-_ -_REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _____________.___-________________) <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------------------------- ------- <br /> I Disposal Field (Specify Requirements) -------------------------------------------------------------------- <br /> - ----------------------------------------------------------------- <br /> i <br /> ------------- -------------------------------------------------- <br /> I <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 perForman f of the work for which this permit is issued, I shall not employ any person in such manner <br /> as tobe5W9subject ork 6n's Compensation laws of California." <br /> Signe - --- - ----------------- - ---------------------------------------------------- Owner <br /> BY ----------- ------------------------------------------------------ Title ----------------------------- <br /> ------------------------------------------ <br /> (If other than owner)4 <br /> }I FOR DEPARTMEtiT USE ONLY <br /> APPLICATION ACCEPTED BY -- -1 <br /> € ------------ ------ - ...... DATE ------- - /_7 Z�---------- <br /> BUILDING PERMIT ISSUED ------------1_____________-- _DATE ------------------ <br /> ADDITIONALCOMMENTS --------- - --------------------------------------------------------------------------------------------------------------------------------•---------------- <br /> -------------------------- -- - ---- ----------------- ------------------------------------- ---------------- --------------------------------------------------------­ <br /> ---- ------- ----------------------------------------- --------------------------------------------------------------------------------------------------------------------------- <br /> i <br /> ------------------------------------------------------------------------------------------------------------------------------ <br /> --------- <br /> Final Inspection by: --------------------- -------------------------------- --------------------Date ------ -] ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M G�f <br />