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' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------- ' <br /> ---------� ----------- <br /> - ----------- Permit No. .(CompYlre Tri tate} - <br /> -------------------------- --- -------------------------- �J r <br /> I <br /> ________ /J_ This Permit Expires 1 Year From Date Issued Date Issued __/-.a_`��' <br /> Application is hereby made to theISan 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 -------- ------------------ ---- -- ----- CENSUS TRACT ----------------------- <br /> Owner's Name � 'C.�f� ��i�i 1�-------•-----,------------- ------------------- _-----------------Phone .-.. <br /> Address --- s__�r____ OX - <br /> °7 dl- 1 city -� /�"�0- --------------- <br /> _ <br /> Contractor's Name -------------------------------License # /_775-1,7---- Phone <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ <br /> Motel F-1Other ------------------------------------------ <br /> 4 r r <br /> Number of living units:._--.----- Number of bedrooms ______Garbage Grinder ./ Q_ Lot Size _14V;�j.S� <br /> ----------•--- <br /> WaterSupply: Public System and name ---------------------------------•----------------------------------------•-----------------------------------_Private ❑ <br /> <u •^ .-.Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ----- ------ 1f yes,type ____.____________________ <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,) U <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] . Size------------------------------------------- ---- Liquid Depth -------------------------- 1► <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 to1 nearest: Well ------------------------ Foundation ------------------------ Property Line _-..-_....______- <br /> SEEPAGE PIT [ ] Depth ----- -------------- Diameter --------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ l\ <br /> a <br /> Water Table Depth ------------------------------------------------Rock Size -------- ----------------- <br /> Distance t Q nearest: Well ________________________________________Foundation __________________ Prop. Line -------___........ <br /> REPAIR/ADDITION(Prev, Sanitationi Permit# ________ ________________________________-_ Date I } <br /> _ _-______._________________________ <br /> f - <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ---.--�_-_aU _ ___ !1___ ,L��1L-'_ J�7,Q__/�._c ��Y,?a ---------- <br /> J_ I------------------------ <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 /> Signed ----------------------- ---Aowner) <br /> ------- ---------------------------------------- Owner _ <br /> By ---------- -------------------------------- Title --------- - - - ------ <br /> ( ther th i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ----- -------------------------------------------------------------- -------------------------- DATE --- -------- <br /> BUILDING PERMIT ISSUED 1 DATE <br /> ------------------------------------------- <br /> - <br /> ---------- <br /> ADDITIONALCOMMENTS - - - ----------------------------------------- ----- ----------------------------------------------------=---------- ---------------. <br /> __ ______ __ _________ _ ______________ _______________________ __ <br /> ------ ------------------------ ------- <br /> - - --- - ----- <br /> ---------------------------------------------------------------------------------------------------------- - <br /> Final Inspection b ��- --------- <br /> - ----a1----------------- <br /> Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,,_�H. 9 1-'68 Rev. 5M <br />