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F R OFFICE USE: <br /> � _ .U,: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) 2 G(D <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued ------------------- <br /> Application is hereby made to the San Joaquin Local Health District for a per 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/LO 'PION w)—e- -------------------------------------------------- ------CENSUS TRACT -------------------------- <br /> Owner's Name v�'r _____ - c ' - <br /> --- --o - ----------- ---- Phone - --7-7-- ...... <br /> Address -------- ---------- ------- city ' <br /> Contractor's Name --------License # -------- PhoneU_----- <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court i❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:----- ---- Number of bedrooms --- 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 1"d Fill Material ------------ If yes, type ---------------------------- <br /> (Piot 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 /> 00 <br /> PACKAGE TREATMENT [ I �- <br /> { ] SEPTIC TANK Size______ _____________--- _--- Liquid Depth ---�-----------••-- <br /> �{ <br /> Ccpacit/1lv-67,0 ; Type ____ - Material___C.U- _c___ No. Compartments __ �........... <br /> Distance to nearest: Well ---- CJD--_ ____ -----------Foundation _fQ_._t------- Prop. Line ___L4.............. <br /> LEACHING LINE No. of Lines .__.__�-_______.__ Length of each' line----------F-dr g <br /> ------------ Total Length ---f PQ............... <br /> Ir <br /> D' Box + Type Filter Material ___evc-k.____Depth Filter Material ----- _ ----------------I.............. 9> <br /> Distance to nearest: Well -_� i.'--y` -'- Foundation ---- _"I/ Property Line <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -------_-------- Number. ________.,_____--__--____. Rock Filled Yes ❑ No ❑ <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 /> 7 <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." i <br /> Signed = -- Owner fX <br /> Title - ------ <br /> BY � -------- = <br /> (If of er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -------- -------- --------------------------------------------------------------------. DATE f I-------------•--- <br /> BUILDING PERMIT ISSUED -------- -------------------------------------------------------------------------------------------------DATE -------------------------------� •---- •--- <br /> ADDITIONAL COMMENTS ------ --- ----- - --- ------------------------------------- --------------- - ------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- ---------------------- ----------------- --------------------------------------------------- <br /> �, Date _ _^_ ._ <br /> Final Inspection by. �JV <br /> `�'�11 t ----------- ---------------------------- -------- <br /> cf ------/------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L/ <br /> E. H. 9 1-'68 Rev. 5M �/ <br />