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R � I <br /> PbR OFFICE USE: f <br /> APPLICATION FOR SANITATION PERMIT <br /> ------- ------- ------------------------ Permit No. <br /> (Complete in Triplicate) <br /> ----------------------------- --------------- <br /> ------------_--------------------- This Permit Expires I! 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 ._ _ c.�.c -- ------------ --------------CENSUS TR <br /> AC -------- - <br /> Owner's Name ------- --------- ------ ----------------------------------- <br /> Phone - - . <br /> Address ------------- - ----•------. City f <br /> Contractor's Name .---,C�l i4�+ _. �'`- - ------------ - -------.License #v?Ss-A----X-- Phone <br /> Installation will serve: Residence Eff-Apartment House❑ Commercial ❑Trailer Court [I <br /> Motel ❑ Other -------------------------- ---------------- <br /> Number of living units:------------ Number of bedrooms .__-----Garbage Grinder ------------ Lot Size -------------------------------------------- ' <br /> Water Supply: Public System and name _J 4,_w Z�---------------------------------------------------------------------•-----Private ❑ <br /> Character of soil to a depth of 3 feet: Sand' Silt Clay Peat 0 Sandy Loam Cla 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,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK'[ j Size___ 6 '_ --------- ------------ Liquid Depth --' .-- '----- b <br /> Capacity as-------,___ Type Material _ No. Comportmenfis ----._.___ .... <br /> Distance to nearest: Well ----------------Foundation _/0--------------- Prop. Line I ------------ d <br /> LEACHING LINE [ ] No. of Lines ____----3_____________ Length of each line____ T------------------ Total Length ---------------- O <br /> 'D' Box _ ______ _ Type Filter Mate rial�� " _-Depth Filter Material ________-/7�__________________________ p <br /> Distance to nearest: Well ___ A4---________ Foundation -----/©_._____---_ Property Line ____ :=.__:�+ <br /> p <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- ,t <br /> I'F Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----.---_----------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> .Septic <br /> -------------.-------------------.Septic Tank (Specify Requirements) - ----------------- ----- ----------------------- <br /> -------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) _____________ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- ---------- ------ <br /> ...� — �_ _._ -- -- <br /> = -- -- -- T _ --- <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 ----= r ------ -Title ----- ----- ---------------------------- <br /> (If other than owner) <br />' FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ` ------ - ----------------------• DATE __ 7 ------------- <br /> BUILb1NG PERMIT ISSUED ------- ------- DATE <br /> ---------- <br /> ADDITIONALCOMMENTS ------------------ -- - - --------------------------- -- ------------------------- -----------------------------------------------------•-•----------------- <br /> ------------------------------------ ------------------------------------------------------------------------ --------------------- --------------------------------------------- -------• <br /> ---------------------------------------------------------------- ----- ------ ------------- �/------------------------ <br /> Final <br /> --------- ---------- _ <br /> -- -- ---- - f -• <br /> FinalInspection by: ----------------------------------------------------------------------------- --- ----- ' �- ------Date ------- <br /> SAN JOAQUIN LOCAL HEALTiIi ISTRICT E. H. 9 1-'68 Rev. SM <br />