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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT----------------------- y y� <br /> - - •---- <br /> ------------�- (Complete in Triplicate} Permit No. ' - <br /> ------------------------------------------- ----------- <br /> --------------------------------------------------------- This Permit Expires i Year From Date Issued Date Issued <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 vies and Regulations. <br /> JOB ADDRESS/LOCATION .- <br /> 11LL -�'�-�-`--�--r�--� ��'�-----�-c�- ----�-+� ����11Y:�j`�� lJS TRACT -------------------------- <br /> Owner's Name Gr- , %r + -'--------------------------- -------Phone ------ <br /> Address ------ - ,777 ---------------------- _ <br /> 'Contractor's Name ----- ------- ---------------------------License Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court °❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:... ----- Number of bedrooms :- ___--Garbage Grinder &V---- Lot Size 47z'(K ---------------------- <br /> Water Supply: Public System and name --------------------------------•- -------------------------- ------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'E] Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.0 <br /> Hardpan ❑ Adobe rOi 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 [ ] SEPTIC TANK f ] 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 -------------------------------------I—.... <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------._.--- <br /> SEEPAGE PIT [ ] Depth -- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <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) -------- ------------------------------ <br /> Disposal <br /> ------------------ -----;Disposal Field (Specify Requirements) --- -_--- <br /> � P N-f <br /> ------------------------------------------------------------- - - -------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 taws of California." <br /> Signed --- ------------------ ---------- - ---------------- Owner 9 <br /> BY --- Title f?� <br /> -------- _� -- -f -V/? _ �s� = -- -------- ------- - - <br /> (If othert an owner <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- - --- -------------- _-- -- ---- ---------------------------------------------------- DATE ---- --------------- <br /> BUILDING PERMIT ISSUED --- --- ------------------ -------------------------DATE ---------------------------- <br /> ADDITIONAL COMMENTS ---------------------------------------------- - --------------------- <br /> -------------------------------------------------------------=--------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- <br /> -------------------- ------------- - <br /> ------- ---- - - ------- ---- ' <br /> -- ---- -------- ----- ----- --- -- ------------ - <br /> Final Inspection by ---------- -- --tom . --------- --------- -------------------------------------------Date- .-- "�� --- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />