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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------- V- - - (Complete in Triplicate) <br /> � ' Permit No. --------------------- <br /> � <br /> ------------" <br /> 4 Date Issued <br /> ---------------------_--------_---------.-------------- This Permit Expires ] Year From 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 <br /> in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . -0cam' =`- ------ ------ - - --------- --------- CENSUS TRACT ------------------- •- <br /> Owner's Name ` :'--- fhL __ Phone . _-. _ _._......_. <br /> Address ------------------- - ---- -r-•--- ------ �C �xA.� City <br /> Contractor's Name ----------- --- --- -- -------- ----- ----- ----------------License #,R _SV----- Phone W 6- 160/--7 <br /> --------- <br /> Installation will serve: Residence*partment House❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:----- .... Number of bedrooms ___ .Garbage Grinder ------------ Lot Size ------------- <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 /> e <br /> Hardpan,❑J,:yrA-dobe 1"if Fill Material ------------ If 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,j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] t Size------------------------------------------------- Liquid Depth -------------------------- <br /> F <br /> -_______________ .F iol��-,V-�CapacitY --------- -------- Type ----- ---.---Material-- ------------------- No. Compartments -----�•--•---•----•- <br /> t� Distance to nearest: Well ---------------�M__ --------Foundation ---------------------- Prop. Line ________________---.•-� <br /> LEACHING LINE [ ] No. of Lines ________________________ Length'of 'each fine k;_ i_.__ Total Length .------------------- <br /> I <br /> t <br /> r <br /> I 'D' Box Type Filter Material ____________________Depth Filter Material __-_____.__________-__-___-__________...... <br /> 4 t Distance to nearest:-'Well ------------------------ Foundation -------------- <br /> Property Line ------------------------ <br /> SEEPAGE PIT [ � Depth __� ___ Diameter ______________ Number _________________________ Rock Filled Yes ❑ No 0 <br /> Water-:Table Depth -------------------------------------------._.Rock Size -----`------- <br /> ------------------ <br /> �" t�� Distancb to nearest: Well ----------------------------------------Foundation -- ----------------- Prop. Line ------..----- -------. <br /> REPAIR/A'DDITION-(#rev. Sanitation Permit# __________________________________________L Date --------------€__________--_._____) <br /> Septic Tan(Specify_Requirements) -------------------- --------------------------------------------------------•-------------------------- <br /> Disposal Field (Specy_Requirements) _________42 ----- 5_ t`rC�- t` L' ---------------------------- <br /> r— __--- --------L__-------------------------------P----------3 -�,' .'a' 7 - -------------------------------------------- ------------ <br /> % I 4 I <br /> (Draw existing'and required addition on reverse side) <br /> 1 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 Warkman's.Compensation laws of,California." <br /> Signed + - --------------------------------- --------- Owner <br /> BY } l Title .. <br /> ------------------ -------- -------------------- <br /> (if o_. rithon•owner) <br /> I J ' <br /> FqA DEPARTMENT USE ONLY <br /> APPLICATION AC EPTED BY ------------------------------------------ <br /> ------------------------------ DATE ...�_ . �7�` <br /> BUILDING PERMIT ISSUED ------------------------- / ------------- ----- -- ---------------------------- [--------DATE _.----------------------------------------- <br /> ADDITIONALCOMMENTS --- ------------------------------------------- ( ---------- ----- ----- -------------------------------- <br /> -- <br /> -- ----------•---------------- <br /> .._.. <br /> -- -------------------------- <br /> --------------------------- ----- - = -------- -- ------------------------------------ - -------------------------------------------- <br /> --------------------------------- `= ------------- -- ------------------- <br /> i <br /> Final Inspection by: -- --- -----------------------Date ------------------------ <br /> HEALTH <br /> - <br /> HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />