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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - ------------------------------- ------------------ ___ I ­,�- -i3 P <br /> (Complete in Triplicate) Permit No. 7_� _.___ <br /> Date Issued <br /> -- = <br /> ------ This Permit Expires 1 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .------ = --------------CENSUS TRACT -------------------------- <br /> Owner's Name I_ J3_f ' - -GC!fi! -------------------------------------------- ------.Phone <br /> Address ____._ __ <br /> .. ,/� -- -- � V_e <� . city - - - - --- -------- <br /> Contractor's Name ----Ut l'=-- _'-- ' f 1- ------------------- ---------License #c --- -_----------- Phone _ 3___:6 - <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ',❑ <br /> i <br /> Motel El Other -------------------------------------------- <br /> f: # o <br /> Number'of living units:------I_----- Number of bedrooms ____Garbage Grinder _-______.__ Lot Size ____________________________________________ <br /> 1 k - <br /> Water Supply: Public System and name ------------ --------------------------------------------------------------------------- Private ❑ <br /> t .tea. ,�. � <br /> -Character of soil to a depth of,3.feet: Sand.'❑ •Silt❑ Clay,.❑ Peat❑ Sandy Loam.-F] 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 /> t <br /> NEW INSTALLATION:`''(No se-ptic'tank or seepage-'pit permitted if public sewer is available within 200 feet,j <br /> llu - <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size________________________________________________ liquid Depth ______.___________.,-____ <br /> Capacity /We -__ <br /> Type ----------- -------- Material------.- ------ --- No. Compartments -------------------_ 0 <br /> .a-.- .� Foundati <br /> '� Disfiance to 'nearest: ell --�=---- -------------------------- --------- - - --- Prop. Line ---------....:..-�---- <br /> LEACHING LINE [ ] No. of.Lines _-:_ -------- L gth of each line-____°___ ______..____._ Total Length- ______._:__._ <br /> - --------------- <br /> '. <br /> D' Box ------------ ilter ateria[ ___________________Dept Filter Material _____________ <br /> Distance to nearell _ _____________________ Foundation ______________________ Property Line. ______________ <br /> SEEPAGE PIT [ ] Depth _______________ ia eter ____-----_-_____ Number ___-_____________________ Rock Filled Yes ❑ No .i❑Water Table De ----------------------------------=------- ock Size ----------------------Distance to nearell ---------------------------------- un ation -------------------- Prop. Line -------------------_.- <br /> REPAIR/ADDITION(Prev. Sanitation Perm _____.___________________________________ Date _--____________________ <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------------- -------- <br /> Disposal Field (Specify Requirements) <br /> - I� � /1/E ,� - ---- --------- _w/—------ �1Y1 C�--------- ' <br /> (Draw existing and required addition on reverse side) tew <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 at 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 Work. an's Compensation ws of California." <br /> Signed ___ _ ____ _ Owner <br /> ------------ - --------------------------------- ----- --------------------- <br /> By ------ --- -- --------------------------- Title - --------------- . <br /> ---------------------------------- <br /> (If other t an owner)I <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _____ ___ ______ DATE _.'k7 ------------------ <br /> BUILDING PERMIT ISSUED ----- -,.N-------------------------------------------------------------------------- -- ----- DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------3------------------------------------------------------------------------- ------------------------------------------- -------------------------- <br /> -------------------------------------------------------------------------------------------- --------------=----------------------------------------------------------------------- ---------------- ---- <br /> ---------------------------- -------- <br /> Final Inspection by. ------ --- --------------------- •----------------------------------- - -------------------Date _.-"1-. ._r - ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Com' <br /> i E. H. 9 1-'68 Rev. 5M <br />