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FOR OFFICE USE: <br /> APPLICATION FOW6 ANITATION PERMIT <br /> -------------------------------- Permit No. <br /> -------------------- <br /> (Complete in Triplicate) <br />� Date Issued <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 existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .___- CZ_ _y _------ �/-�_ ---- -_✓__- -------------CENSUS TRACT ___-___-_____..___.__.___ <br /> ,�tt �t <br /> Owner's Name L- �l�l�� -------Phone ------------------------------------ <br /> Address ----------------- �J' S' �c7.-`L �4-------------------------1--- city � C r <br /> Contractor's Name -----------Se/ --------------------- -----------------------------------License # ---------.-------------- Phone --- -------------------------- <br /> Installation will serve: Residence Apartment House❑ Commercial []Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder _________ Lot Size _______________________________________ <br /> Water Supply: Public System and name --------------- <br /> -----------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand' Siit❑ 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 /> 0 <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 /> ____________________ <br /> Ca acit ---- 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 [ j 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(Prev. Sanitation Permit# ____________________________________________ Date -_-_______________________________) <br /> Septic Tank (Specify Requirements) --------------------------------------------------------------------- ----------- -- --------------------------- <br /> Disposal Field (Specify Requirements) __„��l�O_____-7��/ --- ---- ��----- ----------­--------------- <br /> - ----- <br /> 7�`.c `��--�"�'----"`--`------------------------------------------------ -------- <br /> ----------------------------------------------------------------------------------------------------------_•-------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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, 1 shall not employ any person in such manner <br /> as to beco sub* ct to orkman's Com i laws of California." <br /> Signed - ---------------------------- Owner <br /> BY ---------------------------------------------------------------------------------- ------ Title <br /> -------------------------------------------------------------- <br /> (If other than owner) <br /> F9f DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------= ------------------------------------ DATE ---- -.- ------------- <br /> BUILDING PERMIT ISSUED ------------- --- ------- ------ -----------------DATE ---------------------------•----- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------ ---------------------------------=--------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------__-- -------------------= --------- ----- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- -- --•----- <br /> �•---------------------------------- <br /> - ----- <br /> - Final Inspection by; --- "_ �----------------------------•------------------- --------------------Date -- - ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />