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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - --------------------------- --- Permit No. .7z_��_ _5_. <br /> (Complete in Triplicate) <br /> Date Issued _____________el: . <br /> This Permit Expires 1 Year From Date Issued <br /> -- _ _ <br /> ------------------------------- - ------------_---_ <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 County Ordinance No 9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> �,6� <br /> Owner's Name _. 1,t-i------ - ---- -4,=---_ ._-=-`:-::---`----=------ -----�------------- --- -------------- Phone--- �- --- ---- ------------ <br /> Address ---- -- -----• City ----- ------------------ -------------------- <br /> Contractor's Name _ i ''`' 'y`:1F---.License #e�. ,�f� 1_�__ Phone - <br /> f <br /> Installation will serve: Residence NYApartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:_---_! ---- Number of be ---3------Garbage Grinder ....I------ Lot Size -------------- <br /> Water Supply: 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Size------------------------------------------------ Liquid Depth --- --- .--_---------- <br /> Capacity _f._��d___-___ Type ,�-_�� Material__ �rco~ - No. Compartments ----- _______--__ <br /> Distance to nearest: Well _____,1:0_s'?---------------------Foundation ____/_P___----------- Prop. Line ----�_____ y <br /> h <br /> LEACHING LINE [ ] No. of Lines -------3------------- Length of each line______-/.6-a----------- Total Length ---3 0,0_____________ I <br /> 'D' Box -_LA_axa__ Type Filter Material __ y'3-_______--Depth Filter Material ____415) -----------------------________ <br /> Distance to nearest: Well ________________________ Foundation ____---._a---________ Property Line ___ ........ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 13 <br /> WaterTable Depth ------------------------------------------------Rock Size ----------------------------- - <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------_----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------.------------------------------------ Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------- -------------------------------------•------------------------- <br /> DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- <br /> --------=--------------- ------------------------------ -------------------------------------------------------------- -------------------------------------I----------------------- <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 /> - r------------ <br /> Title <br /> (If other than owner) <br />' FO ,DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- - --------------------- DATE ------- -- --- ----------- <br /> BUILDING <br /> ------ <br /> ---------------------------------------- <br /> BUILDINGPERMIT ISSUED ----------------- --------------------------------------- --------------------=--------------DATE ------------------------------------ ------ <br /> ADDITIONALCOMMENTS --------- --------------------------------------------------------------------------------------------------------------------------------------- -------------- <br /> ------------------------------------------------------------------------------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- <br /> ---------------------------- ------------- -------- ---- <br /> Final Inspection by: --------- Date ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />