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It <br /> . <br /> FOR OFFICE USE: - <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------- ----- <br /> (Complete in Triplicate) Permit No. .__ __�_-_7__9-_ <br /> -------------- --- ----------- ---------- <br /> ----------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ---q__! " <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 w' h County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ,----- --- - ------"- -------------------------- ---CENSUS TRACT -------------------------- <br /> Name ----- ie, ------------------------------------------------------ <br /> Phone � ---- - ----- <br /> Owner's <br /> �F - 1------------- Cit <br /> Cc/ <br /> - - v ------ ---- -- <br /> - ---'- ZG�'��', Phone-14;%7,7----------------------------------------------- <br /> Address <br /> Contractor's Name _ -- _-- - --- - -- ------------------------------License _�A <br /> Installation will serve: ResidenceAApartment House❑ Commercial ❑Trailer Court ;f] <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--- -_- Number of bedrooms -%-?------Garbage Grinder ------------ Lot Sizerx- Qt-�_.. <br /> 452� <br /> WaterSupply: Public System and name -- ----------------------------- -------------------------------------------------------------------------------------------------------Private" <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ 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,) (/V <br /> PACKAGE TREATMENT f ] SEPTIC TANK f ]���� Size----------------------------------------- <br /> .------ liquid Depth -------------------------- <br /> Capacity -.---- T ---------- No. Compartments ------.____ <br /> P Y - ------------ YPe'------------------ - Material------------ --------•-- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line _------------_._-__ <br /> LEACHING LINE >K�_ No. of Linesr <br /> --- --------------- -- Length of each Eine-----��1.'___-- Total Length ------!� -�-------__-. <br /> // . <br /> 'D' Box .-/- Type Filter Materia[ _ ________________Depfh Filter Material -.��_r�---_--__-___---___............... <br /> C t r <br />;y <br /> Distance to nearest: Well ---57 ------------- Foundation 1 ------------ Property Line --''S-----_-__---_--_-- <br /> SEEPAGE PIT Depth �S+-f__- Diameter _�7 rr. Number __._._ __- - _ __-__- Rock Filled Yes Et No <br /> Water Table Depth -----------•........Rock Size <br /> ! i r <br /> Distance to nearest: Well frJC�---------------------Foundation _/ a.----.---- Prop. Line ___ _____•____- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --------------------------------------------------------------------------------- - - <br /> Disposal Field (Specify Requirements] c.CC ,_ - > ------ - t__ - `_ ---- -- - -------------- <br /> ` r `�s" <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 /> "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 Califor'nia." <br /> Signed "f _--__ _--=------- --------------- ------------------ '------- Owner <br /> BY ----- ----- Title <br /> -- --- -------------- -------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- �---"--- � ` — DATE ---- j-7 ------------ <br /> BUILDING PERMIT ISSUED ----- - --- ------------------------------- ---DATE <br /> -- ----------------�-------------------- --------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------------=:T <br /> ----------------------------------------------------_--------------------------------------------------------_-'-•-------------•-------•------_-------------------- ------------------------_. --- ---- <br /> _________________________________________________" --""-----------------"--..--------_-- --------- --------------------.----..-------_----.-.----------------------.-__-------.---------"---- -- "1---- <br /> -----------------------------"--"---- ._ _ - <br /> ___ --- -----" -------- <br /> ---------------•---------••------------•-•-------_----_----_- _- <br /> Final Inspection by: - ---- Date <br /> V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />