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FOR OFFICE USE: (�Z PAPPLICATION FOR SANITATION PERMIT .��3 <br /> ------------- '----------------------------------- \\ (Complete in Triplicate) Permit No. -:1._---.-::,...... <br /> .. <br /> ---------------------...--------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued ___'«_'_7�• <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 ._' __,__ ®_./ leel-/ �-- ------- _ ---------------CENSUS TRACT __--.__-__-___-.._--_-__ <br /> Owner's Name -----�.I.1of//Y/IS------*/WSM-------------------------------------------------- -------Phone <br /> Address � U4!%4fs------'w------ ------------------------ City ------9 ------------------------- ---- <br /> Contractor's Name ___,,k,E '__..__-'____-- --------------------------License # -� . Phone ,T W-.-- <br /> Installation will serve: Residence gApartment House❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----I------- Number of bedrooms -----/-----Garbage Grinder /V0---- Lot Size _. .' -------------- <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ <br /> r <br /> Hardpan ❑ Adobed< 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 --------- -------- 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 <br /> _................ ....SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ,0 <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) ------------------------------------------------------------------------------------------------,-- .......--------------------------------110 <br /> - <br /> Disposal Field (Specify Requirements) ......... X-------__ _ <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 wor r which this permit is issued, I shall not employ any person in such manner <br /> as to become subie to rkma s Com <br /> pen ation laws of California." <br /> Signed -- --------- ------- ---- ---- Owner <br /> By ----- ------ --- -- - -- - ----------a----------------------- Title --------------------------------------------------- ------------------- <br /> (If oth h ow <br /> R EPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- DATE ------- ! (0-777 ------------- <br /> ----------- <br /> ,iI <br /> BUILDING PERMIT ISSUED ------- --------- -------DATE -------------- ------ ------------- ------ <br /> ADDITIONAL COMMENTS ------------ ----------------- --- - - <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- <br /> ---------------------------------------------- ---- -------------------- ------------------------------------------------------------------------------------------- - - <br /> FinalInspection by: ---------- -------------------------------------------- -----------------------------Date ---- ---: d = -- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />