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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------- , <br /> (Complete in Triplicate) Permit No. 7Z___ _-_..__. 1 <br /> -------------------- This Permit Expires f Year From Date Issued 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/LOCATION --------------------------CENSUS TRACT --------------•------- <br /> Owner's Name __.�-�_. __ ____ ___� __�_ <br /> C' � C--------------- --------------------------------Phone --------------------------------- <br /> Address <br /> � Y Lu ---- ------ City - -- -------------------------------------- <br /> ¢ � ---License # _� ------ Phone ---------------- •----- <br /> - <br /> --- <br /> Contractor's Name --- = <br /> Installation will serve: Resident ❑ApartmentHouse❑ Commercial ❑Trailer Court ',❑ <br /> Motel F-1Other ______/&_Z4t <br /> Number of living units:-----1----- 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-E] 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 f ] Size------------------------------------------------ Liquid Depth -------------------------. 0 <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 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# _____________________________ } <br /> --------------- Date --------•---- --•-----------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------- ---------------------------------------------------- <br /> - <br /> -------------------------------------- ------ <br /> Disposal Field (Specify Requirements) -----C'_W-,nX, ____--P - � ��__ _____ _______ _ --------- <br /> ---------- -�__ ____.__ <br /> _ rz <br /> ' - -- ` ---=1---- -- 3 ` =-�= - - -� <br /> .=� --------- <br /> ----------------------µ <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 ----------------------- -- Owner -A <br /> Q <br /> = - <br /> pitle <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY,,,', -- --- --------- -------------------. DATE "`-------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------- ------------------------------ ---- -------------- - <br /> -------- --DATE ------------------------------------- <br /> - - <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------ ---- -------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- ---- <br /> Fina! Inspection by: = Date -"�w`r�-�---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CSS- <br /> E. H. 9 1-'68 Rev. 5M <br />