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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------- Permit No. -- <br /> f0 (Complete in Triplicate) J'3--'-- -?.P <br /> -------------------------------------------------- <br /> ------------------- <br /> PeDate Issued <br /> ----------------------------------------------------------- x' This rmit 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 applic�tiioon is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA71(StZ --___S--____,_4llZ/ l/L -- ----------------------------- <br /> CENSUS TRACT --- _' 1 . <br /> Owner's Name -- - -- -- lZG C - s--------------------------------------------------- -------Phone - 6 <br /> Address 67, 6-- �'----- Od-d /LGl--__/�/__�-�---- City _C� �'j�sl�'�/ ------------------------------------------ <br /> Contractor's Name ___ /_lam-______________________________.License #cd�'1'Q _ Phone6 S <br /> Installation will serve: Residence (Apartment House❑ Commercial ❑Trailer Court <br /> ` Motel ❑Other ------------------------------------------- <br /> Number of living units:-----r_---- Number of bedrooms _.._.Garbage Grinder ------------ Lot Size _ _ _ _ ___________________ <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------------------------------_-_Private <br /> Character of soil to a depth of 3 feet: Sand'($ 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.) Q <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----------------------------------- ___________ Liquid Depth -___________-__---._-___- 0 <br /> Capacity ------------------/e - <br /> e ------------ ------- Material------------ ------ No. Compartments ...................... <br /> Distance to nearest: l __________ __ p. <br /> ----------------------Founda on ---------------------- Pro Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines _______.__ _____ Le th of each line____-___ ------------------ Total Length ----------- ................ <br /> 'D' Box ______ --- Typer M erial __________________Dep Filter Material _________________._-----___-...__..._..-- <br /> Distance to nearest: _____ _________________ Foundatio ____ ------------------- Property Line -_--___-.______--.._..-- <br /> SEEPAGE PIT [ ] Depth _________________ et r _______________- Number ________________________- Rock Filled Yes ❑ No <br /> Water Table Depth - - ------------------------------------- ock Size -------------------------------- <br /> Distance to nearest: W ___________________________ Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________ Date ____-_--____________----_---____-_) <br /> SepticTank (Specify Requirements) ------------ ---------------------------------- ---------------------------- ------------------------•---•----------------------------- <br /> Disposal Field (Specify Requirements) _____ ____ _ _ _____ <br /> 00 <br /> ( and required existing 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 ubject <br /> r tt Workman's Compensation laws of California." <br /> Signed ---- - ----- ---- ----------- --- ----------------------------- ------------------------ Owner <br /> By ------ --- --- --------- LY------ - ---- ---- ---- ----------------------- Title --------------------------------------------------------- ------------- <br /> (If othehan owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------MR-`--- '----------------------------------------------------------------------------. DATE -----J�-� .------- <br /> BUILDING PERMIT ISSUED ------ DATE <br /> - -------------------------------------------------------------------- - <br /> ADDITIONALCOMMENTS -------- ------ - --------------------- ---------- ---- ----------------------- -------------- ---------------------------=--------------------------- <br /> --------------------------------------- ------------ ------------------------ -- -------- - --- - -------------- ------------------------------------------------------------------------------- <br /> ----------- ---------------------------- ------ - -- -------- ---- ---------------------------------------- _ .y <br /> Final Insp ---- -- -�----- ------ ------- -- -- - ---------------------------Date 1 . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />