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FOR OFFICE USE- !F aa ve <br /> ��� APPLICATION FOR SANITATION PERMIT /�- <br /> �� v <br /> --:---- <br /> ----- --- - -----�-------.-- Permit No, <br /> ---------- <br /> .� � (Complete in Triplicate) <br /> ' -- <br /> Date Issued _5 -Z-5_:767 <br /> __J_ 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 Co my Ordinance No. 549 and existing Rules and Regulations: <br /> 'JOB ADDRESS/LOCATION . 0 --- ----- ----- -------------------------------------CENSUS TRACT -------------------------- <br /> - ---------- <br /> Name ,� k'-------- - --- ------------ --- ------------------------- Phone <br /> Address ------ ------- ---------------- ------ --- ----------- City --------------� -----------------------,-=-----------------,--�----- <br /> ;= <br /> Contractor's Name ------------------- --- -- --__-.-__- --_--License# --------- ------ Phone �. _ _f-�__-7_ <br /> Installation will serve:- Residence Apartment House[] Commercial ❑Trailer Court ;❑ Y <br /> ' v Motel ❑Other --------:"--------------------------------- 7 <br /> Number of living units:.... Number of bedrooms ---y_Garbage Grinder --_.------- Lot Size -6-7-- -..--••• <br /> Water Supply: Public System and name ---- ------------------------4 --------------------------- -------------------------- ---------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silto Clay ❑, Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes, type ------------------'-_------- <br /> (Plot plan, showing size of lot, location of system tin relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or speepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ I Size---------- ------------------------------------ Liquid Depth -------------------------- <br /> Capacity <br /> ---_------------- -Capacity ------------- ------ Type -------------------- Material------------ --------- No. Compartments -----------------_--. <br /> Distance to nearest: Well --------------------------------\--Foundation ----------------------- Prop. Line --------------------._ <br /> LEACHING LINE { ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------------ ----_---------- <br /> 'D' <br /> ----------.-----------_---- <br /> 'D' Box ------------ Type Filter Material --------------------Depth f=ilter Material --------------------.----------------------- <br /> Distance to nearest:-Well --=-------------------- Foundation ------------------------ Property Line ------------------------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock=Filled Yes ❑ No <br /> Water Table Depth ------ ------- ------------------------------ Rock Size -----------------.----------� <br /> .'..Distance to nearest: Well-----------------------------_-----------Foundation -------------------- Prop. Line ------------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ________ ----------------------------------- Date ---------------------------------- <br /> ...- <br /> } <br /> _ _ <br /> Septic Tank {Specify Requirements} ---------------- ------------------ ------- .---ul -'Q J------------ <br /> Disposal Field (S ecify Requirements} ----- <br /> ----------- <br /> jf r----- --- - -,---- ----------- <br /> ��c .3 `' a ------ --------------------------------------------------------------------------=------------------------ <br /> ------------------------------- --------- ------------------------------- ------------------------------ ----------=----------------------------------------------- <br /> (Draw existing and required addition on reerse side) x <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 /> {l Chert owner} a 1�. <br /> FOR DEPARTMENT USE ONLY <br /> ` <br /> APPLICATION ACCEPTED -- ----- --- -- -------------------- DATE--------------------- � ---------'- <br /> ----- ------ <br /> BUILDING PERMIT ISSUED -------------------------------------- -- DATE .------___-- <br /> ----------------------1------- <br /> ---------------- <br /> ADDITIONAL COMMENTS ------------- -------------------- -- ------- -------------:--------=-------- <br /> -------------------- <br /> -------------------------'----- - <br /> .--- --------------------- -- -- - ----- - -------------- <br /> - = <br /> Final Inspection by: - - ----- ---- -------------------------- -Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />