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FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT �7 <br /> ------ -------- ---- ----------------------------- Permit No. <br /> r (Complete in Triplicate) <br /> ---- - <br /> ----- ---- --------_------------- ----- ___---,--_-. This Permit Expires 1 Year From Date Issued Date Issued <br /> I Application is hereby made to the San Joaq n Local Health District for a permit to const uct 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 ._- 1--- ----- - - ---------------CENSUS TRACT -------------- ----------- <br />' - ; °---.-Phone._ � '7_ 7 . <br /> Owner's Name ------ -- - -- - - ------ --- ---- ---- --- ---- - ------ <br /> fl <br /> Address -------------------1 ° ` ---------------- •----. City ----------- --------------...... <br /> Contractor's Name ..... ........ f_ ________ Phone __----_J 7 <br /> s License # �C� �r _�-41-( <br /> Installation will serve: i Residence P{rApartment House❑ Commercial:❑Trailer Court ',❑ <br /> t. Motel Other ---------------------------------•---------- <br /> Number of.Jiving• units _ __ Number of �drooms -----____Garbage Grinder _______.--_ Lot Size --- Q � - --.-------- <br /> tiE P - r <br /> Water Supply: Public System and name __�' 'f-------------------•--------------------------------------- 'Q.u4°-----------Private ❑ <br /> �— <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑s/%.CIay. ❑ Peat❑ Sandy Loam Clay Loam ❑ ,; <br /> Hardpan ❑ Adobe-❑ Fill Material ------------ if yes,type _________I_________________ <br /> t <br /> (Plot plan, showing size of lot, location of system�ir relation td'wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank seepage,pit permitted`if'public sewer is available within 200 feet,) 3 <br /> - . ¢ x $, <br /> •' PACKAGE TREATMENT [ SEPTIC TANK '� ire- -- --- ------------ <br /> ----------- Liquid Depth ___S -------------- <br /> { �� <br /> tT e' __!_ Mafieria1_ --�-- No. Compartments __---------�•--_--.. <br /> Capacity FF Yp p _ <br /> 1 ` <br /> Distance to nearest: Well ___-____cY--�____�"____________Foundation __��________-___ Prop. Line ___S------------- W <br /> LEACHING LINE No. of Lines __. __ ____________ Length of ach line.------7..Q____�_------- Total Length .___ .......... <br /> k Depth"'Filter, Material /18-1-_____ ___________________ A' <br /> D' Sox ....✓_ Type Filter Material _ _________ ___ <br /> Distance to nearest: Well ___�� _t'_0_ Foundation ---------- Property tine __ _________________ <br /> SEEPAGE PIT [ ] Depth? __________ _________ Diameter _______________ Number ------ r _Rock Filled Yes EJ No (It,a^ Water'Table Depth ----------------------------- -------Rock Size -------------------- ...... <br /> I E <br /> Distance to nearest: Well ----------------------------------------Foundation -_____._--_____`___ Prop. Line ----- --------------- <br /> - <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------.--------------x----) <br /> M # # J <br /> SepticTank (Specify Requirements) --•------------------------------------------------- -----------------------------•------------------------ ---------------------------- <br /> Disposal Field (Specify Requirements) --------I-_ ' t`- `------- ------- <br /> --------------- <br /> f -------------------------------------------------- ------------------------------------------------ ------------ <br /> A <br /> - <br /> ) <br /> ------------------------ ---------------------------------- ------------------------------------------------------)---------------------------------------------------.------------------------------------ <br /> (Draw existingand required addition on averse`side).,__,T-J <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 /> "1 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 /> . . .�.. <br /> ._— -Owner <br /> Signed -- =- - �_._. ..` .. �. x <br /> --------------- -------- --- --------- ---------------------------------------- <br /> BY ./� --- ------------ <br /> ------- -Title'------ '-- ------------------------------------------ <br /> (If of r han owner] 1 <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> APPLICATION ACCEPTED BY = _ ------------------ DATE ----. ----------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------- ---------------=--------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------- -------------------------•-------------------------------------------------------- ------------------------------------- <br /> t ---------------------------------------------------------------------------------------------------- <br /> --------------------- ------------------------------------------------------------------------------------------- <br /> ----- -- --------------------------------- ------------- -------------------------------------------- _-- <br /> Inspection b ----------------- _ f Date ----j— 1- <br /> Final Ins <br /> P Y: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> F H 0 1-'6.q Rt-v_ SM <br />