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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _7_ZJ3.5 <br /> ---------=----------------------------------------------- <br /> Date Issued _�-�_�_g"_....v <br /> --------------------------------------------------------- This Permit 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 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 .----- - --------- -- ----- -- -•---- -- Phone <br /> Address . - `` ---- --. City --- <br /> r C7 r <br /> Contractor's Name ________ _. � .License #�d-d. - - Phone --------------- -------------- <br /> Installation will serve: Residence ❑Ap rtment House❑ Commercial Trailer Court [1Motel ❑ Other ------4- __________ <br /> Number of living units:_ Number of bedrooms _.__Garbage Grinder __!:� Lot Size ____________________________________---- <br /> Water Supply: Public System and name ___________________(_�___ _ _,T�, _ __ ___ __ __-_______________--_____-__. --____________Private ❑ <br /> T - `_-� <br /> Character of soil to a depth of 3 feet: Sand'Ej Silt❑ Clay ❑ Peat❑ Sandy. LoamClay Loam 0 <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 see ge pit permitted if public sewer is available within 200 feet,) <br /> [ / � /, Liquid Depth _�_�,a---------- <br /> PACKAGE TREATMENT SEPTIC TANK ize-_ __X-�o____X 5 <br /> It Q� Typed-111F_,_; <br /> Capacity _____ ____________ Material---- No. Compartments ________.___ <br /> r 1 <br /> Distance to nearest: Wel! _______�_ ?__©__f_______ _ _____Foundation _- --©__________ Prop. Line __-rs______________ <br /> LEACHING LINE (,(/ No. of Lines -----------1----------- Length of each line--'----- ___ Total Length -----(_6___--___________ <br /> 'D' Box .___ ------ Type f=ilter Material ---__�____R_r---Depth Filter Material --��L___________________------__-_-__._ <br /> Distance to nearest: Well _____ Foundation -------`f7----__........... Property Line ____4%�''__________________ <br /> t i r <br /> [ Depth _____f_�__________ W mEter�'_x___I_�__ Number ________-_f____ _________-_ Rock Filled Yes No <br /> Water Table Depth ------------------14-V ----- --- ._. ._..Rock Size ----Y.X;- _3 <br /> Distance to nearest: Well ---------- —1 9.i__________________Foundation .....1•_0----------- Prop. Line .............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) <br /> SepticTank (Specify Requirements) --------------- ------------------------------------------------------------------ --------------------------------------------------------- <br /> Disposal Field (Specify Requirements) -------------- ------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_------------------------ <br /> --------------------------------- ------------------------- <br /> --------------------------------------- - - ------------------- ------------------------------------ - - - - --- - <br /> - - - - - - - --------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 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 subject to War n's Compensation laws of California." <br /> Signed - -------------------- ---r---- --- --------- Owner <br /> C <br /> BYr-- ----- Title ---- -- ------------------- ------------- ---------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------- --- ---------- DATE --�-�_/3 2_ "----------- <br /> BUILDING PERMIT ISSUED ---------------------------------- --DATE ------------------------------------------- <br /> --------------------------------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------- ----------------------------- ---- ------------------------------------- <br /> ----------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- ------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- ------------------------- ---- ----- ---------------- ----------------- -------------------------- ------ <br /> Final Inspection by -- - ------------------------------------- -------------------------------Date`:'l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />