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FOR OFFICE USE: �PPLICATION FOR SANITATION PERMIT <br /> --------- -------- ----------------------- r� <br /> (Complete in Triplicate) Permit No. <br /> ----------------------- <br /> Date Issuedb_---3_��?3 <br /> --------------- ---------- ----------------------------- This Permit Expires 1 Year From 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 existi g Rules and Re ulations: <br /> ,Ery s Re <br /> JOB ADDRESS/LOCATION//_1/5,OUJ,4 _ _____ -M '_Lf/-__fJ -�C/� /�'P-__CENSUS TRACT ______________________ <br /> Owner's Name --------------- ------OZ010 ---- ------------------------------- q Phone <br /> Address ----------------------------------------------------------------------- Cityl--?`�- _ _ -------------------------------------------- <br /> Contractor's Name ._-___ _ _______� _ ��------------------------License #az `Q____ Phone ! <br /> Installation will serve: Residence 1K Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:__________ Number of bedrooms _-�'------Garbage Grinder __________ Lot Size _______________________:__________________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Wr <br /> Character of soil to a depth of 3 feet: SandfR Silt❑ 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.) <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 -,^/ ---------___ <br /> Capacity <br /> -! Material_(: No. Compartments ___ ..-.._.:....... <br /> Distance to nearest: Well -----------------Foundation __/_U___________ Prop. Line ..4__-.............00 <br /> LEACHING LINE No. of Lines _ f 0 <br /> C l ---3------------ -- Length of each line_ ______________ Total Length �/ _-__--___._-_._.__ 0 <br /> 'D' Box _ _._ Type Filter Material _`___Depth Filter Material ,lf'_______________________________..-.- 1 <br /> Distance to nearest: Well _t�6__�__________ Foundation --------------e________ Property Line _� ________________ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No iC; <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ____________________________-_______--.Foundation -------------------- Prop. Line ----____.-_-___..._--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ____.__-______________--__________) <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------- --------------------- ----------------------------- <br /> Disposal Field (Specify Requirements) _________________________________ <br /> ----------------------------------------------------------------------------------------__-________- <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 become subject to Workman's Compensation laws of California." <br /> Signed -- C--- ----- Owner <br /> ---- - --- ------------------------- <br /> BY ------- --- -- -- -- ---r- --- ----- ----------------------------- Title ------------------------------------------------- <br /> ---------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- -- --=----------------------------------------------------------. DATE -..... �'�-----/ ------- ------ <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------- -------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------- ---------------------------------- --------------- ----------- <br /> -------------------- ------------------------------------------------------------------------ ---------------------------------------------------------- ------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- --------------- <br /> -----------------------------I--------------- <br /> ---------------------------------------------------------- -------------------------------------------------------------------- --------- <br /> Final Inspection b - - Date <br /> - ----------- ----------------- <br /> P Y: ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />