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"O!t OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: ------------ <br /> - <br /> -------- ------- ------------ This Permit Expires ] Year From Date Issued Date Issued _ 63----- <br /> 112 <br /> ------ <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..�.��xi?ANr��_W� ��.°�-- l���y°- �_)��_�------------------------------------CENSUS TRACT ��-----------_-- <br /> Owner's Name ---------------------lS1l�l-LmAlz 1u___I:o-------------- <br /> -------------------------------------------------------Phone ------------------------------------ <br /> Address ---------- -------- ------------------nSM-----=------------------------------------------------- City ---------------- <br /> Contractor's Name ---------------------()t,13_Tl f4Z----------------------------------------------------License # -------- .---------- -__ Phone ------------------------------ i <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court i❑ <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 /> 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 /> R <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) \ <br /> PACKAGE TREATMENT f ] SEPTIC TANK![ ] Size----------- ------------------------------------ Liquid Depth ___________________..____ <br /> Capacity -------- -{Type -------------------- Material---------------------- .No. Compartments ' <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------:-------- <br /> LEACHING LINE [ ] No, of Lines ----- -------- ------ Length of each line--------------------- ------ Total Length ,_____-__-___-___________� <br /> 'D' Box ----- Type Filter Material ___________________Depth Filter Material ___________________________________-_.__.- <br /> Distance to nearest: Well ---------------------___ Foundation _------------------ _ Property Line <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter _______________ Number ----- ---------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------- <br /> ---------------•--._._.Rock Size ---------:---------------------- � <br /> E <br /> Distance to nearest: Well _______________________________-___-..Foundation -------------------- Prop. Line ....____..______.._... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____---_________._________________) <br /> Septic Tank (Specify Requirements) - L 1*iC+h ------�----- �A_�5-------------------- <-----------=F--------------- <br /> Disposal Field (Specify Requirements) ------------- - ---------------- -------------------------------------------------•--------------- <br /> a <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 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 beco ub' ct to Workman's %r�ensatron law f California." t <br /> Signed --- ---------- Owner <br /> By ----- ----------------- --------- -- ------------------ ----------------------------------------------- Title ----------------------------------- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------------------------------------- -----------------—_%-------------. DATE ------------------------------------------- <br /> BUILDING PERMIT ISSUED -- -- ---------------------------------------------------------------------------f------: -------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------ ------------ ------------------------------------=-------•------------------- <br /> --------------------------------------=------------------------------------------------------------------------------- --------- -------------------------------------------------- ----------------•- <br /> - ----_ <br /> - --------------- <br /> --- =� <br /> Date- / <br /> Final Ins ection by: _______ ___ SSAN JOAQUiN LOCAL HEALTTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />