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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....................... ....... �, � <br /> (Complete in Triplicate) Permit o. - - <br /> .......................... <br /> --- This Permit Expires 1 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 compliancewithCounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION H-_a-/_.._ .....1� -17-4----------------------- <br /> . __------------------- <br /> .-CENSUS TRACT ----•--- <br /> Owner's Name --� / 122t ' -------------------•---------••---------- ------ ......Phone <br /> Address - ---- - ------..f-. -----•---------------------- ----• --------- City ---------------__---_-.--._------ <br /> Contractor's Name ----�r-=__.t-_t,(y---- ---------------License # ------ ----------- Phone -------------- --•--• ....... <br /> Installation will serve: Residence;f Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other <br /> Number of living units_____________ Number of bedrooms ............Garbage Grinder ---....----- Lot ........................ <br /> Water Supply: Public System and name -------•----•---------•--•------•----- -----•------------ •-------- ---------_--------•-------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Q� Clay Loam ❑ <br /> Hardpan ❑ 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK.[ I Size................................................ Liquid Depth .........._.-..._._-_--._- <br /> Capacity ---------- ----- Type ----- -- ---- ----- Material---- ----------- ._ No. Compartments •--- ................ <br /> r <br /> Distance to nearest: Well ._----------------_...___.----..--Foundation ....... Prop. Line ................ r <br /> LEACHING LINE [ J No. of Lines -____.___.___..-- Length of each line ------------- -._._ Total Length ----- ...................... <br /> 'D' Box ------ _---. Type Filter Material --------------------Depth Filter Material .................._-_.-----__..-__--..... Al <br /> Distance to nearest: Well ........................ Foundation ...__..._. -------- Property Line ___._.__..___.-._-_-__-. <br /> SEEPAGE PIT Depth --------- ------ Diameter ................ Number -------------__.---------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------ ------------••- ---------_-Rock Size ------- --------------------•--- <br /> Distance to nearest: Well ........................................Foundation .... --------------- Prop. Line ..............-....... <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date .-._-_--_-_. __---------------) <br /> SepticTank (Specify Requirements) ----- -- ---------•-•------------•---------•-----•--------•----- ----•-------•--- ------•------•-----.__---------------- ..... <br /> Disposal Field (Specify Requirements) --- �,�' ..12c _--------------- <br /> ---­---------------- 4 <br /> •-----•------------- ---------------- ! -s" ;,4_. = '``-.--.--------------------------------------..-------------.--------._----_---_---- <br /> ------ - --- - ---------- ----- --------------------- ..... ---- --..._ ------------­---------- ------- --------------------- ---------.--------------------------------------------- <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 Son 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 performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become ubja to Workman's Compensation laws of California." <br /> V <br /> Signed --- �- --1 -- - ----------------- ----- ----------- Owner <br /> BY - - - -------------------------- ----- ----- --- ------- --------------- ----- ------ - Title .. . - --- ------ -----...-_........ -------------- --- <br /> (If other tho owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --.•..•-•..............• .......... DATE _1-r�._.'_f.3_....................... <br /> .....-•-•--•--••--------------•- <br /> BUILDINGPERMIT ISSUED ------------- --------------------•-----•-•---••---------------•-----•-=...........--..................DATE . ---••-•---•---•--._... _-_ ---------- <br /> ADDITIONAL COMMENTS ---------------------------------- <br /> -------- -------- ------------------------------------------------------------ -- ---------- <br /> ------------- -- ---------- . <br /> - -------- = <br /> FinalInspection bY: - . ----------------------------•--........_...---------........-------•-•--..Date?. n- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M - <br />