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FR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Complete in Triplicate) <br /> Permit No. _T_3_ <br /> Q <br /> --_---__-__.-____-_--__--_ This Permit Expires 1 Year From Date Issued 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 /> -- -----------.--.----:----- -----------CENSUS TRACT -------------- ------- <br /> JOB ADDRESS/LOCATI N __ _S__ ®-___:, _ ________.._ <br /> Owner's Name - �'r`'G --------- -- - <br /> --------------------------------------------------------------Phone ---------------------------- <br /> Address -----------------1' --------- ----Jam--------------------------- . City - C ('�---••------ <br /> Contractor's Name ------------------- ----------------------------------------------------- ------.License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel E)-Other ___________,___Number of living units:------------ Number of bedrooms ______•___Garbage Grinder ___-________ Lot Size --- ---------------------------------------- <br /> - s <br /> r Water Supply: Public System and name ---------------------------------•---------------------------------------------------- I----- 1--------------Private ❑ <br /> a <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt F] Clay ❑ Peat❑ Sandy Loam .E] Clay Loam ❑ <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 public sewer is available within 200 feet,) x' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![ ] Size-----------------------------------•------------ Liquid Depth ---------------,._____--._ O <br /> Capacity -------------------- Type •------------- Material*' --.....-------- No, Compartments ------- -----•--- 11� <br /> i <br /> i Distance to nearest: Well _____________________..Foundation --------------------- Prop. Line --------------_......_ <br /> LEACHING LINE [ ] No. of Lines --------- -------------- Length of each line_ ------------------ _______ Total Length ............................ <br /> 9 <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 I❑ <br /> E Water Table Depth ---------------------------------------=--------Rock Size -------------------------------- <br /> 1 Distance to nearest: Well ------------------------_---------------Foundation j: ________ __�-__ Prop. Line :____........ ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___1,--t --I----v-_ M' Date ___ <br /> l <br /> SepticTank (Specify Requirements) -------- -----------------------------------------------------------------------------------------------------,._-----------------------,-- <br /> DisposalField (Specify 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 /> "1 certify tha ° the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to bee b° ct to Wor n's C mpensation laws of California." <br /> Signed .. --------------------------------- Owner <br /> By --------- ------------------------------- --------- Title ---------- ---------- <br /> --------------------- - ------------------------------------------------ <br /> (If other than owner) <br /> FQR� EPARTMENT USE ONLYA7 Z <br /> APPLICATION ACCEPTED BY ------ - ----- - ---------------. DATE - <br /> BUILDING PERMIT ISSUED _________ ____ ______ ___ _ ______--_DAT F,�� _: _____________. ,, <br /> - ------- --- ----------------------------------------------- <br /> i ADDI I TIAL COMMENTS - --- -- - - - - --- - -- - - - --` --- <br /> - ---------- - c,' 4,-- -- T,� ` f�-L .. <br /> - -------------------------------------- -- ,:. <br /> ---------- ------------- - ---- - <br /> Final Inspection by: ------ -- ----- - - - - �^�r ----------------------------------------- ----------------- ------Date - <br /> SAt�I`,OOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />