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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------ ------- ---------------- ------ ----------- 13- �3 <br /> (Complete in Triplicate) Permit No. - - -- <br /> -------------------------------------------------------- <br /> - ----- �_ Th}Perm.t Expires 1 Year From Date Issued Date Issued <br /> ------------------------------ ------ -------------- <br /> Ol 7--0'60�Z I <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. T is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> tf7 rf b 1R. �Eu�r�� <br /> JOB ADDRESS/LOCAT ON ._.___ ___ _ -_��----�?_---' __ `"..----�� r------CENSUS TRACT __' _ �............. <br /> Owner's Name .-- .---- �.- ----------J .- - Phone <br /> Address ,�0i------f 'yk------ --------------------------------------- City <br /> Contractor's Name ----------------------------------------------------------------------------- ----------License # -------- --------------- Phone ------------------_------_ <br /> Installation will serve: Residence ❑ Apartment House^❑ Commercial,]Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms ____________Garbage Grinder ------------ Lot Size _________________________________________ j <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 ❑ O <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 /> NEW INSTALLATION: {No septic tank or seepage pit permitted if publi sewer is available within 200 feet,) <br /> SEPTIC TANK / <br /> PACKAGE TREATMENT [ Size__yL_t___! + <br /> [ l ------------------- Liquid Depth <br /> Capacity 1_,krl______ Type ___4C.&-r Material....4A-6--------- No. Compartments <br /> Distance to nearest. Well ___ __"_____________________Foundation ------------ Prop. Line --- --_____________ <br /> LEACHING LINE [ ) No. of Lines -----/----------------- Length of each line-------P_O--- ---------- Total Length._ijfl-- <br /> 'D' Box __ "' ___ Type Filter Material A__ J�-------Depth Filter Material ---- 1_----------------------------------- <br /> Distance <br /> _____________________________Distance to nearest: Well f�a'-------------- Foundation -------------- Property Line _ .._._______........ <br /> SEEPAGE PIT [ ] 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 /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- <br /> Field <br /> --- ------ <br /> Field (S e - Requirements) -- ------------------------•-----------------------------------------------------------------------------------------•--------------- <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 <br /> By ------ --------------- ----------------------------- --- ----------------------------------- Title --------- - ------------------------- ---------------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ ' _ ------------------------------------------------------------- DATE Z''__e� 5-73_____________. <br /> BUILDING PERMIT ISSUED ------------- -------------------------------- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------•---•----------------------------------------------------------------=--------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------ - ------ ---------------- ----- --- ----------------------------------- <br /> - -------- --------------------------- <br /> --------- ------- - -------------------- <br /> Final Inspection by: ---- -----------------------------Date id---------�-'�------------ ------ <br /> ----- -- - ----- - - ---SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />