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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------- Permit No: --7----------5._� <br /> II (Complete in Triplicate) <br /> ---�! Date Issued ___`--�._:_Z_`�_?v ' <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application ishereby 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 yy�� <br /> %LOCATION __�`(a.���-----/y,--�:--- ��.--i- - --------- ----------- ------------------- CENSUS TRACT -----...------- <br /> Owner's Nam <br /> Address - _! ------- ^-^- -- - ------------------------------------- ----------- -----------------Phone ------------------------------------ <br /> l ----------------------------------------------------------- ; <br /> city <br /> Contractor's Name jam - .-.License # ��T`.3. _y_ Phone ---------------------------•-- <br /> Installation will serve: Residence PtApartment House❑ Commercial❑Trailer Court ;❑ <br /> Motel ❑ Other ----------------------------- <br /> Number of living units:------ Number of bedrooms ----3---Garbage Grinder -- Lot Size -------------------------------------------- <br /> Water Supply:i;Public System and name ---------------------------------- ----------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ SandyLoam ❑ Clay Loam ❑ <br /> Hardpan Adobe ❑ Fill Material ----------- If yes, type ----------------------------- <br /> 4 <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: 1Nd septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size---------------_------------------------------- Liquid Depth ---------------------------- <br /> Capacity----------------- <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 ------_---_-----.-------_-_---_-.._--------- <br /> Distance to nearbsf--Well ------------------- Foundation ------- ---------------- Property Line __---._----_--------- <br /> SEEPAGE PIT [ ] Depth ---- ---- - <br /> _ <br /> ---- _-- Diameter ---------------- Number ---------------------------- Rock Filled Yes E] No i❑ <br /> "i Water Table Depth ------Rock Size -------------------------------- <br /> Distance to nearest: Well ------------------ ---------------------Foundation -------------------- Prop. Line ----_-_.__....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------- ----------------------- Date ----------------------------------I <br /> SepticTank (Specify Requirements) ----------------------------------------------I------------------------ --------I---------------------------•,•---------------------------- <br /> p Field (Specify Requirements) ft! - � �-�-r� r"� <br /> Dis osal Fie CJ <br /> �;- "-- -----2 - <br /> ---------- ------------- ----- <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> By ------ <br /> Signed -------' ------- Owner <br /> -- --------- -- - - <br /> ------------------ <br /> - --------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- DATE ' +. ' <br /> ---------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------- ----------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------- --- -------- ----------------------------------------------------------- <br /> ------------- <br /> ----------------------- H------------------------------------------------------------------- <br /> - ---------------------------------------------------------------------------------- <br /> -------------- <br /> ----- --- -------- ------ --------- ---------------------------------------------------------------------------------------------------------- -------------------------------- <br /> ------------------------'�------------- <br /> ------------------------ <br /> ------------------------------------ -- - ----- ---------------- ----- -- --- --- <br /> - ---- --- ----------- <br /> Inspection'by: Date "" - <br /> - ------------------------------------------------------------------ ---- --- --------------------------------- <br /> Final SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M J <br />