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FOk�01T-PICC USE:­ <br /> I <br /> - <br /> �� I APPLICATION FOR SANITATION PERMIT <br /> 7[ ----------- -- ------- Permit No. <br /> II (Complete in,Triplicate} <br /> - -------------- --------------------at--------=" �`�J <br /> Date Issued ______________� <br /> This Permit Expires 1 Year From Date Issued <br /> �N ` <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein' , <br /> described. This application is' made in complicince wit- ount- Odin ce-Na. 549' and existing Rules and Regulations: <br /> JOB <br /> ADDRESS/LOCA I� --------------- ------CENSUS TRACT -------------- -------•--- „ <br /> - -- r-- --- ----- -- - <br /> Owner's Name - n -------- <br /> Owner's <br /> . City ._�l/ i <br /> Address ------------ E ------------------------ - �� -- - -- <br /> ----------_ - <br /> Contractor's Name ___ __. _____Ali --- License #/-0/ 5U"a Phone _-_ ___ --�--•- _,�' <br /> Installation will serve: I Residence XWO—clrtment House❑ Commercial ❑Trailer Court <br /> 4 <br /> g Motel ❑Other -------------------------------------------- <br /> 'i <br /> ------------------------- ---------------- <br /> Number of living un�ts:�_ _ ___ NumberLT drooms _ Garbage Grinder,,4/0__._ Lot Size dpo_ -------••'- <br /> hi <br /> Water Supply: Public Systeme 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 sA_9-"2'__ If yes, t <br /> (Plot plan, showing size ofl�lot,locatio6 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 /> . E <br /> PACKAGE TREATMENT I ] �I SEPTIC-TANK"L ] Size------------------------------------------------ Liquid Depth --------------------------- <br /> ,I � <br /> ! Capacity ---------- ------- Type -----------=-------- Material---------------------- No. Compartments --------------- •---••o� <br /> �.___4 ..,.. ti., <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------_---------------5 <br /> LEACHING LINENo. <br /> [ ]� �;of Lines --:--------------------- Length of each line----------------;----.-- -- Total Length ,----------.-----------•_---� <br /> D' 1113ox ________/ Type Filter Material ___________________Depth Filter Material --------------------.-----------------....__ <br /> Distance to neareft: Well ------------------------ Foundation .----------------------- Property Line. -------_-------- ....... <br /> SEEPAGE PET [ ] i Dept h _.______ Diameter _______________ _Number ----.___________-_____---- Rock Filled Yes ❑ No C] <br /> ' 1pth ------------------------------•------- Rock Size <br /> Water Table De ------------ ------ 1 <br /> r i . <br /> Distance to nearest: Well ____________________________I-----------Foundation ---____________-__ Prop. Line .:..______--__--_____� <br /> 4 I I <br /> REPAIR./ADDITION(Preva Sanitation Permit#-•------------------- -------------- --------Date--------------------._..---------- <br /> Septic <br /> ____----Septic Tank (Specify Regu'irements)------ ---------- - ----------- - -------` -----•----------]------ --------------------- <br /> p Y ��---------- <br /> Disposalr .------- <br /> Field (5 ecif R <br /> e�ujrements) ------- - rP <br /> ------------------------------- <br /> -------------------------- <br /> ----------------------- ----------- --------------=--------- -------------------------------------------------------------------------------------- ------------------------------------------- <br /> II (Draw existing and required addition on reverse'side) , 1 <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 /> '� t ` <br /> sed agents signature,certifies the,following: I <br /> "1 certify that,in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner J y <br /> as to become subject to Wo <br /> rkman's Compensation laws of California." <br /> • <br /> Signed C .-- ----I4-I-------------- _- ---- ------- Owner <br /> - Title `- _ <br /> - <br /> -- <br /> BY --------------------------- <br /> (If ot�er tha I'.vv ed ; <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED8Y ------------------------------------------------------ -------------------- ----- DATE - -�S-7 <br /> BUILDING PERMIT ISSUED 'i---- ----------------- ---------------------- -- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS A----------------------------- ------------------------------------------------------------------ --------------------------- <br /> -------------------------------------------- <br /> ------------------------------- ------------------------------------------------------------------------ ---------------- -------------------------------------------------------- <br /> 1, <br /> ------------ ---- ----- ------ --•----------------------------------------------------------------------------------------------------------- <br /> ------ -------------------------------------------------------------------------------------------------------- -------------------------- <br /> Final Inspection by: ---- ����--- =�-------=----------------- -------------------------------------------------- ----------- <br /> -----Date ---- 5- }----------------------- <br /> n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '�ov • C� <br /> E. H. 9 1-'68 Rev. 5M <br />