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1 <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------�--------- --------------------- �2_'G__y_y <br /> (Corrlete in triplicate) Permit No. <br /> =------------------- ------------------------- <br /> _____ This Permit Expires 1 Year From Date Issued <br /> 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 County Ordinance No. 549 and existing Rules and Re lays: <br /> JOB ADDRESS/LOCA ON ---/- � ----------------------------------- --------CENSUS TRACT l.C1C'QE'/j� <br /> ° Owner's' Name L/ 7---------------- 1` -------------------- ------------Phone atal -1 + <br /> Address, -7- Ifeli6 fA1�------�Al—---------------- CitY �����Q��-----------g-S7 <br /> --------- g 5 <br /> Contractor's Name T"�-L -------------License #&,2-W-3------- Phone ------------------------------- <br /> 6 l <br /> Installation will serve: Res idenceXApartment House-'Commercial:El <br /> Trailer Court ;❑ <br /> Motel f] Other -------------------------------------------- p ----------- <br /> ' <br /> ---_Garbage GYrinder- Lot Size -_- __X-d-- ---- <br /> Number of living units:--- Number of bedrooms <br /> /-__ _ ----------- ; <br /> Water Supply: Public System and name _4 f- y -------- --- -- ---- ---------i�f-[1------------------'Private ❑ k <br /> Character of soil to a depth of 3 feet: Sand[] Silt❑ C1 ❑ Peat❑ Sandy Loam -❑ Clay-Loam ❑ <br /> Hardpan ❑ Adobe II Material ------------ If yes, type .____`_______ <br /> (Plot plan, showing size of lot, location of system I% on to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or s epage t permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT f ] SEPTd TAN Size------------------------------------------------ Liquid Depth ----------- -------------- <br /> E V}' <br /> Capacity ---- --------- --- pe -------------------- Material---------------------- No. Compartments ------ ............... <br /> Distance to eaves ell ------------------------------------Foundation ---------------------- Prop. Line --.--.---- ------ <br /> LEACHING LINE [ ] No. of -nes ________-- Length of each line--------------------- ______ Total Length ,__________-___--_------_... <br /> 'D' Box ._ ____ __ Type Filter-Material ____________________Depth Filter Material ------....................................... <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _____-____._--__--..-__. �+ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ______________ Number ---------------------------- Rock Filled Yes ❑ No .0 <br /> Water Table Depth ------------------------------------------------Rock Size ----- -------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------..---.. <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date -----------------------------_--._) <br /> SepticTank {Specify Requirements) -------------------- ------------------------------------------------------------- ---------------------------------------------•----------- <br /> Disposal Field (Specify Requirements)/tP-_W------C1V jK----C?AP- -----SL--GG- - e_-1-----l--j'-------- ---GL, <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: l <br /> "I certify that in the performance of the work for which this permit is issued, II shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - --------------------- --- -------------------------------------------------------------------- Owner. <br /> I <br /> BY -------------- ------------------------------- ----------------------- -------------------------------- Title <br /> (If other than owner) <br /> FOR DEPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY - �- ..---- ------------------------------------------------- DATE -- --------- I, <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE --------------------------------- --------. <br /> ADDITIONAL COMMENTS ----------------------- = <br /> ------------------------------------------------------------------------------ ------- <br /> ___----------_-------------------------------------------------------------------------------------._-yE---------------------------__-------------------------_____--------------------------------------- <br /> ------------------------------------------------ <br /> --------------------------------------------------- <br /> Final <br /> ___ ___________Final Inspection by: -----------------------------------------------------------------------•---------------------------------------------Date ---------...------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M. <br />