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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------- ------------------------------- 7�-- -7F <br /> --- Permit Na_ _________________ <br /> {Complete in Triplicate) <br /> ----------I---------------------------------------------- <br /> ---------------------- This Permit Expires 1 Year From Date Issued Date Issued/_5-43_-7-3 <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 _ 6-51 - --------- ---3-a----- ------------------- ----------------CENSUS TRACT <br /> Owner's Name// ( 1 ------------------` -- `� ---------------------------------------------=- ---------------..__Phone <br /> Address ---- t -- — --- City ------------ <br /> yy� <br /> Contractor's Name -------- -----/�"--_--0,�_- - --- ---.1- -License .-�� Phone -J <br /> Installation will serve: Residence [gApartment House❑ Commercial:❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units. ----- Number of bedrooms -----I-----Garbage Grinder ____ ------- Lot Size _.950 __._ <br /> Water Supply: Public System and name -----------------------------------•--------------------------------------------------------------------------Private Pd <br /> ,,�,,, , -Character of soil,to.a depth_of,3 fegt...,-Sand-;❑_Silt.❑._Clays❑ Peat❑ Sawn& oam ❑ Clay,Loam ❑ F <br /> Hardpan ❑ Adobe X' Fill Material ------------ If yes, type -------------------•-------- <br /> t <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 [ I SEPTIC TANK'[ ] ff <br /> Size_____ .. ------------- <br /> _ _� _ __ Liquid Depth <br /> Capacity/ 4___.__ Type 'Materiaf ___ No. Compartments �________________ 6 <br /> Distance to nearest: Well __,&O-------------------------Foundation 12 e---------- Prop. Line _ ______________ <br /> LEACHING LINE { ] Na. of Lines ------'� .------------ Length ch�iine_____ __ ____ Total Lenge'J ®................ <br /> D' Box __. ___.__ Type Filter Ma#erial ____________________Depth Filter Material _ _ ___________.__ _______---.--_- <br /> Distance to nearest: Well ------4M-------- Foundation _____ �__________ Property Line *�_______________. N <br /> SEEPAGE PIT [ } Depth -------------------- Diameter ________________ Number -------- ------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth - -----------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ----------------.---- Prop. Line --------------- ------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------_----------------------------------- Date ____---___________________________) <br /> Septic Tank (Specify Requirements) -------------- ------------------ ------------- ------ �1 <br /> Disposal Field (Specify Requirements) --------------------------------- --------------------------------------------------- <br /> - ------------ - -- ------------------------------------- <br /> (brow <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 -- --.. - - ------------------------ -------------------- Owner <br /> BY - --------------- Title ------------------ <br /> ---------------------------------------------------- <br /> (If other than owner} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------- -------- DATE ----------------•------------------- <br /> ----------------------------------------------------------- ------ <br /> BUILDING PERMIT ISSUED ---------------------- -----------------------DATE ------------------- ------- <br /> ---------------------------------------------------------- -- -------------- <br /> ADDITIONAL COMMENTS --------- -------- --------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------A----------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----------- <br /> ------ ------------------------------ ------- ------------------------------------------ --- ----------------- ------- <br /> Final Inspection by: --------------------------- ---------------------------------------- --------- ----- - -- -- - ------Date __._lt �= ----------- <br /> SAN JOAQUIN LOCAL HEA ISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />