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FOR OFFICE USE: APPLICATION 'FOR SANITATION PERMIT <br /> ------------------------ Y/�� - <br /> (Complete in Triplicate) Permit No. _7-------- ------------------------------------------------ <br /> ----------- --------_-___---__-------___________----- This Permit Expires 1 Year From Date Issued Date Issued <br /> �. 0ZS_--0` 0 03 <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 9nd Regulations: <br /> •Z4 'u3 ; ,G cJt ' �r/ar r-/1rasa <br /> r3lOBADDRESS/LOCA.IO1V . /J /� ��I//, i�lf '/© c O't11 -------- -;CENSUS, CT _,S^^ ,%. <br /> Owner's Name --------/:��71------------------------------------------ -------Phone ---------------------------- -------- 4 <br /> Address --------- ------------------ Cit 1 <br /> -------------- ----------- <br /> Contractor's Name ----4�7 414-j-X111-e/�---------- ---------------------- License # Phone - ---------••------ <br /> Installation will serve: Residence ❑ Apartment House�❑ Commercial ❑Trailer Court ❑ f <br /> 1Z� { <br /> Motel QOther --- ..,6 �'-------- <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder -----__----- Lot Size �_- - -------------- <br /> -�-- : . <br /> Water Supply. Public System and name _______________ } ----------- va _ <br /> _ r to <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat Sandy Loam ❑ Clay Loam ❑ <br /> r <br /> Hardpan ❑ Adobe'❑ Fill Material ----- ------ If yes,type ____-----________________ <br /> W <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,) t <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size------------------------ _`.'_--- = ,,liquid Depth --------------------_--- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------•--------------- <br /> Distance to nearest: Well ------------------------------------Foundation ..-------------------- Prop. Line ___-_-___________----_ <br /> LEACHING LINE [ ] No. of Lines ------------------------ 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 i❑ _ <br /> WaterTable Depth --------------------------------------- -------Rock Size --------------------------------- <br /> Distance <br /> ------- ---•------Distance to nearest: Well --------------------------------------- Foundation ---------------r` Prop. Line -•-------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _______ ------------------------- Date ____----_____-_____.__--__________} <br /> ----- '> ' <br /> Septic Tank (Specify Requirements) --------------- �" f �-------- ----------------•---------- <br /> Disposal Field (Specify Requirements) 'cf� <br /> ----------- --- ----`----------------------- <br /> ------------ - <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 sign ature'certifies the following: <br /> "I certify that in t.' e. or acao he work for which this permit is issued, I shall not employ any person in such manner <br /> as to become ct orkma s Com ensation laws of California." <br /> Signed ---------- --- - - - -- -------------------------------------- Owner <br /> BY --------------------------------- ------------------------------------------- Title ---- -------------------------------------- ------ '-------------------- <br /> (If other than owner) <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY' - -- ------ -- ----------------------------------------------. DATE 1- '-'�6`�- <br /> --�..�r-- - -- -- -_+7c;[---------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ----------,--------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------•----------------------------------------------- -:---- --------------------------- <br /> ----------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- ------------ - - -- -------- -- -- ------------------------------ ----------------- - -------------- -------------- ------------- I------------- <br /> ----------------- <br /> --------------------------------- --- --- --- --- -- ------------------------- <br /> - <br /> Final I ni pection by• ----- � --------------------__-----------------------------------Date - .. ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />