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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- - --------------------- ----- f4 <br /> (Complete in Triplicate) Permit No. <br />` _____-____ This Permit Expires T 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 Rules and Regulations: <br /> JOB ADDRESS/LOCATION �J 'y ----- --------------CENSUS <br /> TRACT --------------. <br /> Owner's Name ----116)t_Fk------- -- -- - ------------------------------------------ Phone --------------------------- <br /> Address -------------- <br /> ---- -- ----- <br /> Contractor's Name --------- ,�_ _ License # -ffJ.PYPhone ---------------------------•-- <br /> Installation will serve: Residence Apartment House-❑,Commercial_❑Trailer Court ❑ <br /> l ❑ o- 3 Gdrba" e'Grinder _L-~ <br /> Motel Other ------------------------- -- D <br /> Number of livings units:----./ Number of bedrooms""'" ___._ - g _�_:___ Lot Size _______________________________"____________ <br /> Water Supply: Public System and name --------------------------------------------------------•----------- ;--------------- -----------Private <br /> Character of soli to a depth of 3 feet: SandF] Silt❑ Clay ❑ Peat❑ SandyrLoam [ lay Loam[] <br /> Hardpan ❑ Adobe❑ Fill Material ___________ If yes, type__________________________ <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be'­placed on reverse side.) Q <br /> NEW INSTALLATION: (No septic tank or seepge pit permitted public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT . [ ] SEPTIC TANK, Size J_ __X`_._______ --------- Liquid Depth __________________ <br /> NI_�Capacity �-__d_______ Type _ ___ _ _ Material-_ �1�,: No, Compartments _��.______________ <br /> ' x S rT <br /> Distance to nearest: Well ___-___- ""_r""_____ ____; Foundation <br /> ------r_q�__r....... Prop. Line <br /> LEACHING LINE <br /> [ No. of Liries ______ ------___-__ Length of each aline--------- Q------------- Total Length ---------- <br /> 'D' Box ----� Type Filter Material ----5--/-.Depth Filter Material ______ _____ _________________ <br /> Distance to nearest: Well _____S_6___________ Foundation ------)-b-------- __ Property Line ._.S___________________ <br /> 3 <br /> SEEPAGE PIT [ ] Depth ________ Diameter ________________ Number ----------------------------- Rock Filled Yes ❑ No i❑ <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 Field (Specify Requirements) ------------------------------------------------------------------------------------------ -- --------------------------------------- <br /> I <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 /> "1 certify that in the performanc of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to W mans Compensaon ws of California." <br /> Signed ---------------- -------- ------- ---------------- -- ----- -- -- ------------ Owner <br /> By -------------- ------------- ----- ------- XitIe --- <br /> (if othe owner) <br /> 1+ FOR DEPARTMENT USE ONLY > <br /> APPLICATION ACCEPAD]'B <br /> --------------------------------------- - ----------. DATE ---- ---`�--f�---�-�-------------- <br /> BUILDING PERMIT ISSUED -------------}---------------- --------------------------------DATE ------------------- <br /> ADDITIONALCOMMENTS #---------------------------------------------------"-------------------------------------------------------------------------------------------- <br /> ---------------------- ---------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- <br /> -------------------- ------------ 1-------- -- ------------------------------------------------------------------------ ------------------------------- ------------------------ <br /> i <br /> ---------------------------------- -------- ----------- •-- -- ----------------------------------------------------------------------------------- --:7q- <br /> SAN <br /> - ------- <br /> --- ------- <br /> Final Inspection by: ---------------------------------------------------- -------------------------------Date ---------1 /_'�-�7. - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />