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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: ----------------_--- <br /> ----- <br /> .��-.J� - <br /> ti.-------�------ ------------ --•--------- --------- (Complete in Triplicate) <br /> ----------------------------- 7 <br /> --- p Date Issue <br /> This Permit Expires 1 Year From Date Issued <br /> a �-YA plica on he by mode �o the Son Joaquin Local Health District fora permit to construct and install the work herein <br /> described. This application yyis//me�a//de in compliance with County Ordinance No. 549 and existing�Rules and Regulations: <br /> JOB ADDRESS/LOCATION!Y�_1/4��-� __ -_Ir-J-W,04i ~1V--------------------------------CENSUS TRACT -------------------------- <br /> Owner's Name -----1AIC, - <br /> - Phone <br /> 1111 = ------------------------------------------------------ ------------ <br /> ---- - - �--------- <br /> Address _ /y)-----'--------- ----------------------------------------- ---- City c-- � � /�------------- <br /> Contractor" Name - f ------ �C <br /> f License # _ --K Phone <br /> { <br /> Installation will serve: Residence&OApartment House❑ Commercial ] 4Trailer Court i❑ <br /> Motel ❑ Other ------------------------------------------- <br /> Number <br /> --------------------------------------- -Number of living units:_-'"`._- Number of bedrooms __ _Garba_ge Grinder Lot Size - ----------------- <br /> Private-[P <br /> Water Supply: Public System and name -------------------------- <br /> ---------"" -- - ---• ---- -=------ ----------------------------------------- { 4 <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt EyJ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ------------ 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.)i t . <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) c W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ a Size-----------------------------------•--- Liquid Depth ------.---.----------.-- <br /> _. <br /> Capacity - Type -------------------- Material--------------------- No. Compartments �-� <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----•-----...-------- <br /> _.: <br /> LEACHING LINE [ J No. of..Lines ------------------------ Length of each line---.------------------------ Total Length ---------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------•---------------- <br /> [ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------­- --------- <br /> SEEPAGE PIT [ ] Depth ----------- <br /> --- Diameter --------------- Number ---------------------------- Rock Filled Yes El No <br /> Water Table Depth Rock Size -------------------------------- I� <br /> Distance to nearest: Well ----------------------------------------Foundation _.------------------ Prop. Line ---------------....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) r ► <br /> Septic Tank (Specify Requirements) -- - -- -- -----------------------------------------------------------------------------------------------..-------------------------- <br /> ments} ______ -- - '57-71.;M <br /> fiA -02�---------'57-. 10;11 <br /> ; ------ <br /> Re '! I mo' <br /> Disposal Field (Specify quire - - <br /> �7 'r <br /> li f s' l ------•---------- <br /> -------* ,f/ <br /> ---- ------------------------------------ ----------------------------------------------------------------------------------- ------------------------------- -------- ------------------------------------ <br /> (Draw <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 /> "1 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 Work n's Comet nsatio' laws of California." <br /> Signed -- <br /> s f ------------- -- Owner <br /> ----------- --------- - -- --- -- -- -- --- -- - <br /> ------------------------------ Title ---- - --------- ------- ------ --- ----- <br /> ---------------------- <br /> (If other than owner) <br /> kF R PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - -_ -----____-. DATE `;- ---- -�-' 8--- <br /> BUILDING PERMIT ISSUED -------- -------------- ---------DATE ----------------------------------------- <br /> tADDITIONAL COMMENTS ------- - ---- --- ----------------------- ------------------------------------------------------------------ ---=--------------- <br /> } --------------------------------- ---------------I------------------------------------------------- <br /> ------------------------- - <br /> --- <br /> --------- ------- ---- -------� " ' ` ' <br /> - ---------------------------------------------------------- ° __ - ---------------- ------ <br /> - - -------------Dat ----- <br /> Final Inspection����-- -----------�- - -- -- ---- -- - -�--------- ---�- <br /> I' ----------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k <br /> E. H. 9 1-'68 Rev. 5M. <br />