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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------- --------------------- Permit No. --77�=--6-7 7 <br /> (Complete in Triplicate) <br /> -------------------------------------------------------- - <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued _(_-L_6------ .v <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/LOCA N 5o1V` 1�__ -Gx��a� �__��_ „-�'-._ .-- - VE TRACT <br /> . a <br /> NSUS --•----------------------- <br /> -- <br /> Owner's Name <br /> �w»- --A ------------ ----- - ----- Phone <br /> - ---------------------------- --------------------- <br /> Address -------- City --- 3 _ _ ,7[?3 <br /> ----------------------- <br /> --• U <br /> Contractor's Name (-- ----- -- -------------License # `cog ----- Phone ---------------•------ ------- <br /> Installation will serve: Residence ❑Apartment House,F] Commercial ❑Trailer Court ',❑ <br /> Motel ❑ Other __ __ '-___ <br /> Number of living units;-------______ Number of bedrooms _%L_------Garbage Grinder ------------ Lot Size ____________________________________________ <br /> i <br /> Water Supply: Public System 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 ____________ If yes, type ---------------------------- <br /> (Plot <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 [ ] SEPT A 6►,] Size__ _1__`__�C-S__`________________ Liquid Depth __C/--�_______________ <br /> Capacity -------- - ------ T eE __-- Material- --- - -•-._-• <br /> p y yp 9 No. Compartments <br /> Distance to nearest: Well ____________✓5_--a�________________Foundation ----!_o__--_______ Prop. Line ___ r___�__________ <br /> LEACHING LINE [j(] No. of Lines ____�_______________ Length of each line-----ya '----_ ----- Total Total Length _/60 <br /> 'D' Box __/- ------ Type Filter Material ___.__g_ ____Depth Filter Material ------/_!�_'-___--____----------------- <br /> Distance to nearest: Well ------Sd-------------- Foundation ------!Q............... Property Line --- ............ <br /> SEEPAGE PIT ] Depth ___________________ Diameter ________________ Number __________________________ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to,nearest: Well ________________________________________Foundation ---------------4---- Prop. Line --------- ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------_----------------------------- <br /> DisposalField (Specify Requirements) -------------------------------•----------------------------------------------------------------------------------------------------- <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 signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 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 /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - _ -'- DATE .----_- - --------------- <br /> --=--------------- ----------------------------------------- <br /> BUILDING PERMIT ISSUED ------------------- ---------------DATE -------- ---------------- ------------ <br /> --------- <br /> ADDITIONALCOMMENTS ----------------------------------- ---------------------------------------------------------------------------------------------- --------------------------- <br /> ------------------------------------------------------- --'---------------- ----------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- --------------- - -------------------- --------------------------------------------------------------------------------------------------------------- <br /> ------------------------------ ---- - --- <br /> -------- ------- - <br /> - - -- --------- -- - - - ------ <br /> Final Inspection b : -- ------- ------------------ ---- - ---------------------------------------------------------.Date __..`tea= <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M _ <br />