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FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT ,_� • <br /> " - _7--_ <br /> (Complete in Triplicate) Permit No. <br /> Dp <br /> ---------=------------------------------------------- <br /> --------------------------- ----------------------------- This Permit Expires 1? Year From Date issued `1 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 co pliance with Count Ordi No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --- .1 `�~:--- ------------- ------------- _ANSUS!TRACT -------------------------- <br /> Owner's Name -. - -1_y_- X1 .4- .1� Phone <br /> t' f <br /> n V�+ - --- - --• Cityfnyh <br /> izo - ---------------------------�-j-- <br /> ------------ <br /> Address ti1 ! g�s , Phone 5Contractor's Name --------- ------- --�-----------Lice <br /> Installation will serve: Residence 5]Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:_ Number of bedro ms ----____Garbage Grinder ------------ Lot Size __ - _ �_ 0_____________ <br /> Water Supply: Public System and name _mr, -��----LLJ ; ---------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'[' Silt❑ Gay ❑ 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC T ] Size___t _ _ ._____ -_- Liquid Depth -----=7 <br /> Capacity l __ ___ Type` RMaterial__ ro. Compartments _- ............... <br /> Distance to nearest: Well --------��--�______________Foundation __/.l-L?__/-__ Prop. Line ..-C,— .-�_____ Ii\ <br /> LEACHING LINE [ ] No. of Lines -----Z-------------- Length o each line--------- Total Length ---- <br /> � <br /> 'D' Box ------------ Type Filter Material _ _ ___________Depth Filter Material ---ZY_/r.......................... <br /> Distance to nearest: Well _____ __________ Foundation ____ __________ Property Line ----is. <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ______________ Number ---------- ----------------- Rock Filled Yes ❑ No C] <br /> Water Table Depth ------------------------------------------------Rock Sze -------------------_ <br /> Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ____-_____--_:----__-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------•-------------------} <br /> Septic Tank (Specify Requirements) ----------------- ------------- ---- --------------------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 becomesubiect to Workm s Compensation laws of California." <br /> Signed ------ --------- ------------------ t --- ---------------• Owner <br /> B <br /> y ------ ---------- ---• ---------------------------- _ Title --------------- <br /> ----------------- ---------------- ------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ---------------------------------------------------------------------- -------------------------- -- DATE ------------------------------------------ <br /> BUILDINGPERMIT ISSUED ------------- ---------- --- -----------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS .C:_•-/-------- y`�°- -------------------g--------------------------------------- <br /> ------------------------------------------------------------------ <br /> -------------------------- ------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------- <br /> ----------------------------------------------------- ----- - - - - - - <br /> - - ----------------------- <br /> - ------------------------------------ - ----------------------- - -------- - - -- <br /> Final Inspection by: �} --`---- `° --------------.Date z� -------------------- <br /> SA JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />