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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ...............I.............�.`:3�.i Permit No. ...� <br /> i {Complete in Triplicate) <br /> ......._................................................ I <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 mode'in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ......�- <br /> JOB ADDRESS/LO TIO ..,�:�o..l......�.__.�.:'T"-"�--.�.... ._...-•........ ...... . .. ...............CENSUS TRACT ................ <br /> r <br /> Owner's Name .. -!r� !l:J...LQ..`v ' pe.c+w�!'r�l..:.........Phone� /..7�'. ....... <br /> Address .... -��.__7�-�. -----•-- .. ��t.ri1 .+_............__ ....... City ... .. <br /> Contractor's Name ......__. license #. .'. Phone .. ........�6 . ... <br /> .._. � ............ <br /> Installation will serve: Residence []Apartment Hou '❑ Com rcial :❑Trailer Court ❑"'a. �� � „s -- <br /> Motel 0 Other ....... ..... . •-------- <br /> Number of living units:............ Number of bedrooms Garbage Grinder ............ lot Size ....-`.................. l <br /> Water Supply: Public System and name .................................._............................................................................Private) <br /> Character of soil to a depth of 3 feet: Sand❑ . Silt❑ Gay ❑ Peat j] Sandy loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe)]' Fill Material ............ If yes,type+...q....................... <br /> (Plot pian, showing size of lot, location ofsystem 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 J SEPTIC TANK ' ite-.__-_x __x f....................... Liquids Depth ......- ---•-_ '.. <br /> Capacity« . _.._...Type . ........ ........ Material_..._--_-. ....... Na. Compartments .. <br /> ..o......... .. <br /> Distance to'-nearest: Well ... 4' .........4 ...Foundation ... Pro p. <br /> ._f�.:f— ... 1©....:�-- Line � <br /> LEACHING LINE No. of-Lines �f... length of ea line._____.lv??.`...._. :;;•Total length�._.Z.�....-._.-•_--- <br /> F,. k .... . .. <br /> Box ....... Type-Filter Material Depth Filter'Material __-"./i..........••-• ............... <br /> Distance to nearest: Well .... Foundation r:t...... Property Line ....4'�.. f ........ <br /> SEEPAGE PITS Depth ..>. Diameter .�.��....... Number ......J.... Rock Filled Yes-VI No <br /> Water Table Depth .. Rock Size 1. <br /> z.'...... . - <br /> Distance to-nearest: Well ..---- .......................Foundation .G:a`........ Prop. Line,.....---•-----........ ' <br /> REPAIR/ADDITION(Prev. Sanitation Permit-W.,=.......................................... Date ..................................11 <br /> ..� <br /> Septic Tank (Specify Requirements f #' i <br /> % . <br /> Disposal Field (Specify Requirements) <br /> :...-•-•--- <br /> - ... <br /> ------------------------------------------............--- --......-•---------- ._.- --••••-••-••......-•----......_ •--- <br /> ....--••------••-•---•-•-•••-------- •--._.......... ------- <br /> 1 � <br /> ....................•-----------.--.......------._._.............._._....-----•-•--•- ------ -- -- ----------..•••... -•...-•-- ---.........----....... <br /> t <br /> (Draw existing and requireci-addifion on reverse side) <br /> I hereby certify that I,haveprepared.this-applicction and that ,the work will be done in accordance with San Joaquin <br /> County-Ordiriancei,"State Laws, and Rules and Regulations of-the San Joaquin Local Health District. Home owner or licew <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 Workman's Compensation laws of California." I <br /> Signed ........... ........... -- -•-•-•--- .........................:.. Owner <br /> By .......... ... ........ ......I.._.. .'.....:._.._........- ._...._.........---••--•-........................... Title Title....__.:.......... ......._....__.._._....................__...-_ <br /> (if other th wned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ......9_ .b`''13 <br /> BUILDINGPERMIT ISSUED ... ... .......: ..................................................................DATE ........................................... <br /> ADDITIONALCOMMENTS ..................................................................---•......-......•................................................................. ........ <br /> •••••_.... ------ <br /> .............................. ----•-.. ............................................... .---------------------------------------- ........................................ <br /> -•----------------------------------------------- ..... <br /> ..... � <br /> - Final inspection by. ...:.... . .... • - -- - - ----------=--...._.......:...........:......:...................................Date ... .�r��_.3 ......... <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> r F_ w_13 24 1.`68 Rev. SM �� 7/72 3 X � <br />