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FOR OFFICE'USE: 4� <br /> APPLICATION FOR SANITATION PERMIT <br /> �a (Complete in Triplicate) Permit No. <br /> _. ------------- - <br /> ._____--_-__ This Permit Expires ] Year From Date Issued Date I 6-6d <br /> Applicationds. 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 ounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . <br /> - - .,......_�.�_ --- _----CENSl�S TRAC-T-_-_:---_---_--=•----- <br /> Owner's Name ---------- xl .5 - Phone <br /> ---------------------- <br /> Address a...... �-Gz-t-�--•--. City - ----- ----- <br /> Contractor's Name -------- jj- ------- f - -------------------- --------License # !- rPhone S'.��' <br /> Installation will serve: Residence partment House,0 Commercial ❑Trailer Curt ;❑ <br /> Motel ❑Other ---------------------------------- <br /> Number of living units:_._- _____ Number of b rooms _2,_-___Garbage Grinder _. Lot Size -- ---o------ ----------_.____ <br /> Water Supply: Public System and name ___-_ f---------- --------------------------------------private F1 ,. <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan E] Adobe 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,)-,.,.- <br /> A <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] °'' Size------------------------------------------------ liquid Depth -------'------------------- <br /> r� _ --=1 <br /> . � - <br /> Capacity ---- -------- - -- Type --------- ----- Material------ -- ---`--- No. -,Compartments -- ------- <br /> Distance to nearesf Well _-- '-------------------------` --Foundation ------------"._----_ Prop. Line -------------:...----- <br /> LEACHING LINE [ ] No. of Line's` ________________________ Length of each line _________-_-------_.____-- Total 'Length_________-_..._..___________ <br /> `D' Box ------------ Type Filter Material -------------------- Filter Material _____---------- I <br /> ---------------------------- <br /> Distance to nearest: Well ______-________________Foundation ------ ---------- Property-Line ::__�_______-_------___ <br /> SEEPAGE PIT [ ] Depth Diameter ________________ -dumber .____ ---------------------- Rock Filled Yes Q No I❑ <br /> Water Table Depth ------------------------------ ------.'Rock Size ------------ ------------ <br /> Distance to nearest: Well ----------------------------;-----------Foundation _____._____--------- Prop. Line <br /> k� <br /> f <br /> ___.__..__._ <br /> ---REPAIRJADDITION(Prev Sanitation Permit# • Date -•------------­-------------- <br /> Septic <br /> ----------- ---------------Se tic If <br /> Tank S ecif Requirements) � �.� <br /> / <br /> Disposal Field {Specify Requirements) r- � <br /> ----------- -.f - I& ------------------------------------------------------ <br /> ---------------- = # <br /> =--------------------------------------------------- -------- <br /> Mi (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:`7 4 t <br /> "I certify that in the performance of the•work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becomes ect to Work m n' nsati.on laws of California." I <br /> Signed ' <br /> - --- <br /> BY <br /> -- f - 4 TFtlea <br /> ------------------------- <br /> ---------------------- <br /> n other thaowner � <br /> FOR DEPARTMENT�llSE ONLY <br /> APPLICATION ACCEPTED BY .__1__ ---- ------ - <br /> �� <br /> -------------'-------------------------------. DATE _5 )S_------- - .-------=- <br /> BUILDING PERMIT ISSUED DATE ---------- -------------------------------- <br /> ADDITIONAL COMMENTS ---------k <br /> ` - - �-- - - f- <br /> -------------------------------- <br /> t - -------- - ------- ----------------------------------- - - <br /> ----- ------------------- -- -- <br /> ------------------------------------------------- --------- <br /> ---- - ---------- - <br /> ------------------- -------- ------------- - - ---------- <br /> ---------------------------------------------------------- ----------- �----- --- <br /> Final Inspection by: ------ -- - --- ----------------------------------------- ------------------- ------------------.Date -----.r -�---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5lU1 r <br />