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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------------- ------------------------------ Permit No: <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued7-,?l_-I'_?-o <br /> -------------- 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. This application ijjs��made in compliance with County Ordinance No. 549 and existing Rules and iRegulations: <br /> JOB ADDRESS/LOCATION .7._ --------- - ------------ - _ --- ---------__ _________- "m---CENSUS TRACT --------------•----------- l <br /> Owner's Name <br /> ---- ------- ---------- ---Phone------------------------------ <br /> T7 7 <br /> --- -- <br /> ` <br /> aAddress ------ <br /> Contractor's Name ------ �� - ------ -- =--License# Phone ------------------------------ <br /> Installation will serve: Residence Apartment House-0 Commercial :❑Trailer Court 0 <br /> Motel ❑Other --�---------------------------------- <br /> Number of living units:_________ 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❑ Cl El Peat ElSandy Loam IDClay-Loam.E] <br /> Hardpan E] Adobe' Fill Material ____________ If yes,type ---------------------------- <br /> (Plot <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 I ] Size------------------------------------------------ Liquid Depth -----------------.-- ----- <br /> Capacity -------------------- Type -----------------:-- Material---------------------- No. Compartmmerils --------------_---- <br /> Distance to nearest:.Well ----------- - - .Foundation ----------------------Prop. Lane --------------__ <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line---------------------------- Total Length .---------------------------- r <br /> 'D' Box ------------ Type filter Material --------------------Depth Filter Material ----------------------------_------_-------- <br /> Distance to nearest: Well ----------------------- Foundation„------------------------ Property. Line. ---_-----_--------_---- <br /> SEEPAGE PIT [ I Depth - `--------------- Diameter ----------------------------- Rock Filled Yes [] No <br /> Water Table Depth ---Rock Size -------------------------------- <br /> Distance <br /> ------------------ -Distance to nearest: Wel( ------------------------------------- --Foundation -------------------- Prop. Line ------------------- <br /> RIEPAIR/ADDITION(Prev. Sanitation"Permit�# -------------------------------------------- Date ---------------------------------_) <br /> r <br /> SepticTank-(Specify Requirements) ------------------------------------------------------------------------------------------.------------- ,------------------------- <br /> Disposal Field (Specify Requirements)---------------------------- ----------------------------------------------------------------------------------------- <br /> a` _ : ---- - -- ------- f-0-_' �` ---------------X 2.f`- ------------------------ <br /> ----- <br /> --------------------- i <br /> Y q� <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 Wilk lien Joaquin <br /> County Ordinances, State Laws, and Rules and RegulwOms of the San Joaquin Local Neafth District_Name ownw or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the wont for vAoicfi this permit is issued, 1 shall not employ any poepw 4n so m muner <br /> as to become sulsject to We n Compensation laws of t aliifon4o." } <br /> Signed -------------------------------=---- --- ---- ------- -S--- --- - --- -------------- Owner <br /> BY ----------------------------------------- Title --- `-- -------------------------------------------- <br /> - (If other than owner) ` <br /> TM- <br /> •DEPMT SNT USE ONLY <br /> 7 <br /> APPLICATION ACCEPTED BY ` - - ---------------------------------------------------------- -- DATE ----7-- - v-------------- <br /> BUILDING PERMIT ISSUED ------------- ---------------------------------------- <br /> -------------------------------------=-------- -----DATE ------------------------------------------ ; <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------=--------------------------- <br /> --------------------------------------------------------------- ----- ----------------------- --------------------------------------------------------------------------------------------------- <br /> _______.____Y------ <br /> ___------ <br /> _________ _________ _ _____________ ___---______ __--------------------------------------------------------------------------------- <br /> _____________•-_-__-_f _ _______ <br /> _ ________________________ _ __ ___ ________________________ --------------------------------------------------------------------- <br /> ______ <br /> Final Inspection by: ------ - Date ------- _ `7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />