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J r <br /> FOR OFFICE USE: APPLICATION APPLICATION FOR SANITATION PERMIT <br /> ---------------1--//%�-------- 0 Permit` No. �0� <br /> ,/1 I (Complete in Triplicate) <br /> � f/ <br /> ----------------------------------_---------------------- v\ This Permit Expires 1 Year From Date Issued 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 /> JOB ADDRESS/LOCATION ._- .___ !____/�.,__ ___ _ ------------------CENSUS TRACT .......................... <br /> Owner's Name / <br /> ------ - - -----------------------------I--------- Phone - -�_��f_6J� <br /> Address --------------------------L ------------ City --- ------------------------------------------ <br /> Contractor's Name ___________fia, <br /> ___ _____r______ __ --_ _-______._.______.License # � ��---___ Phone -1-64---- <br /> Installation will serve: Residence <br /> ;4partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ----------------------- -------------------- / <br /> Number of livingunits:___L______ Number of bedrooms _- _-_-___Garbo a Gri der ___ Lot Size _-6-@___Xi <br /> O 9 P �, 1 <br /> Water Supply: Public System and name ______--___-__-__________________.__ _ -- -- (.0 Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'-- E] Silt❑ Clay ❑ Peat❑ Sandy-Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe/K <br /> FiII,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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is a,vairgble within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------.----------------- Liquid Depth -___-__----._-__.__-_--_-- <br /> Capacity -------------------- Type -------------------- Material-------------------- No: Compartments ...................... <br /> Distance to nearest: Well ------------------------------------Foundation---------`------------- Prop. Line ----___-_-._...___---_ <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 ---------------- Number ----------------------------- hock Filled Yes '❑ No i❑ ' <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line .................... <br /> IIEPA11t/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --------------------------------- --- ------ ----------------- ---- ----------- ---------- ------------r <br /> Field (Specify Requirements) ----------------aAa �------- .__-- <br /> ,p ------------ <br /> ------------------------------------------------- -----------------------------------------4--------------- N ek -- ---'K-----------•------------1y <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 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 -----------------------Jab <br /> ------- - Owner <br /> ------------ <br /> By ----------------------- - t'----- Title --------- -- <br /> (If otherer) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED Y - /Isl --------------- <br /> DATE _ /1 0-----------• <br /> BUILDINGPERMIT ISSUED ---- ------------ ------------------------------------------------------- -----------------------------DATE --------------------------- --------------- <br /> ADDITIONALCOMMENTS -----------------------------------------------------------•--•------------------------------------------------------------------------------------------------ <br /> ----------------------------------------------------------------------------------- --- - - --- - <br /> -------------------------------------------0--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------NIQ ---- <br /> -------------------------------------------------------------------------------------------------------- - ----- <br /> Final Inspection by: -- -- ---- - - - Date �-1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M ,7 <br />