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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> •--•--..---.....___­1.............••----- (Complete in Triplicate) Per No. .�� , <br /> ' <br /> .............. . This Permit Expires ! Year From Date Issued ,J <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 ..�eA�1.........CENSUS TRACT --------_----••-•-....... <br /> Owner's Name .L at/ /k}edL•t�}--- _-.:-:-------------------Phone <br /> Address ...x !rJ��------•----------------•-----...----........-----...--•--- --....City OF- hone ._..---......_...........---- <br /> Contractor's Name -----------------------------------------------------------i........License# -------------------- -.._ P <br /> Installation will serve: Residence❑Apartment House f3 Commercial oTrailer Court .0 <br /> Motel❑Other............................................ <br /> Number of living units;-_)...... Number of bedrooms 17........Garbage Grinder ..?IA----- Lot Size &.61O.Vo--•------------------•-__--:_ <br /> Water Supply: Public System and name ----..................... ..............................-----------------------------------------------------Private g <br /> Charocter of soil to a depth of 3 feet: Sand o Silt❑ Clay C] Peat❑ Sandy Loam 1] Clay-Loam X) <br /> Hardpan jR Adobe'M Fill Material ............If yes,type...........•--•-------•••••. <br /> (Plot rjan, 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 700 feet) <br /> PACKAGE TREATMENT [ l SEPTIC TANK:[ l 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 <br /> ......... Length of each line---_-_--------- Total Length ;_____.-_-_-__--_-___.--_--_ � <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material -----__----- ••------------- <br /> Distance to nearest: Well ........................ Foundation ....... f roperty Line .•_.--_•--__- --_-- <br /> SEEPAGE PIT [ ] Depth . _ _.,_. .._____.. Diameter ................ Number ........................ Rock Filled Yes 0 No 0 <br /> Water Table Depth ---.............................. ..............Rock Size -_-------- ................... <br /> Distance to nearest: Well ........................_____...........Foundation --._.....___-. ..... Prop. Line ._......._.._.. i <br /> REPAIR/ADDITION(Preva Sanitation Permit# _-__•....................................... Date -...._----------------. ------••-) ,. , � <br /> Septic Tank (Specify Requirements) ____ ___ ___ ________________________ __• - T ..' � <br /> Disposal Field (Specify Requirements) ----••-----------=-•----••---...•..--•--•---•---•---•---••-•---------•-••-•--------.•._-------•-----.----------_._._-•--------------- <br /> ................................................................._.............................. ...--........................ <br /> ............................................... ....................................... --• -•---...-.------.•------------•---....._..--•--•-•-••-•-•••--•.......--•-••......----.........---- ......--•- i <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 Sart 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 <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 .. -... :. -• - - Owner <br /> BY .•._._. 1(/_. �!l i f...--•-•-. ............. Title _..................... <br /> (if other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY... .. ... . ------•---................ DATE '�`� --------• .................. <br /> BUILDING PERMIT ISSUED----•--• .......................................... --------.......----- QATE .. - <br /> ADDITIONALCOMMENTS..................................................................... .............................................................------------------..._-••_.. <br /> ................................................................_.�__.�.......•---•-.......-•---....._......-----••-----......••-----•-•••-•-•----•---•----•-•--•--•--•••.......... <br /> ---------------------•--------••-------- -----........-------------••--------• -•-------•----...................-............................................................... <br /> ... .. <br /> .......... <br /> c . • - - <br /> Final Inspection by: ............................••---• -•---..... _ .....--• ----•--•--•---- . Da e --•- •-:764f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />