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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ---------------------------- = -------- ; <br /> � � <br /> --------- ------- --------- --------- p{Complete in-Tripficdte) <br /> Date Issued <br /> /----1-- --------- This Permit Expires 1 Year From Date Issued + <br /> F <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.-549,and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _/_�_ 6F. <br /> fa7ytG I � 1.D - ------CENSUS TRACT ------------- <br /> Owner's Name -_ -- ----- -------- -- - ---------------------------------------------------------------------- <br /> Address <br /> Phone <br /> Address ---------- ---- ----------•-------- --- ------ City --------------- ----A----------------------------------------------------- <br /> Contractor's Name _/1 /.r--- --- ------ ------ -------- `-'�-------------License # vF' �_ __ Phone <br /> Installation will serve,. — Residence Apartment House-F-1 Commercial ❑Trailer Court :❑ <br /> Motel ❑Other ----------------------------------------- <br /> Number of living units:----1------ Number of bedrooms ---�!------Garbage Grinder __ -- Lot Size __0Z0_X---a-b----------------• <br /> Water Supply: Public System and name ------------------- ------------------ ---------------------Private <br /> Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ ~-Sandy Loam ❑ Clay Loam 0 <br /> Hardpan ❑ Adobe-❑ Fill Material -----i__i-__ If yes,type ---------------------------- <br /> (Plot <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 f ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth __------------------ .---- <br /> Material-e' No. Compartments _�...............Capacity --- Type _ - <br /> U <br /> 4 <br /> Distance to nearest: Well _______ D0-----------------_Foundation _--�__8-____ ___� Prop. Line .__ `_______....__ <br /> LEACHING LINE [ ) No. of Lines __.__3--------------- Length of each line------ _4------------- -Total Length __3a a-____.....___- <br /> r/ <br /> 'D' Box -"-- Type Filter Material 1/ktw(Depth Filter Material ----J9_____________--------------------- <br /> Distance to nearest: Well __/X_tf---.-------- Foundation -------------- Property Line-5 7---_________________ <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 /> SepticTank (Specify Requirements) - ---------------------------------------------------------------------------•---•----------------------------•- --------------------------- <br /> Disposal Field (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 become subject to Workman's Compensation laws of California." <br /> Signed - -----------------------or----------------------------------------------------------------- Owner <br /> By ----- ------------ --------------------- ---- Title --------------------------- ------------------------- ------------------ <br /> (If other an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- --1'------ -------- DATE __-- _7//-'-s------------- <br /> BUILDING PERMIT ISSUED ----- ------------------------------------------------------------ <br /> ---------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------ --------------------------------------------------- -------------------------------------------- ------------------------------------- <br /> ------------------------- ---------------------------------------------------------------------------- <br /> ------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------- -- ------------------------- ---------------------------------------------------------- <br /> -- <br /> � <br /> --------------------- DateFinal Inspection bYt ----- <br /> SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />