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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No <br /> + d (Complete.in Triplicate)�J _ _. ......._._ ._. _ ` . f <br /> � ---•�--x�- <br /> .................•-------------......--------- <br /> .... This Permit Expires I Year From Dablssued flats Issued .. .. .�.'',2 <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 qounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRirSS/LOCATION .- .. ..'R.._ .. . ............. ....CENSUS TRACT ......... .,.............. <br /> - 1 --•• ..... <br /> Owner's Name - .... ............... . .......... +!J`il ....................:.................Phone ......... ,......................... <br /> Address .... ity ............................................. ............ <br /> Contractor's Name ...... .... .... 1 <br /> ............License # . .., ,3 Fes, ' . Phone <br /> IfI <br /> Installation will serve: Residence 0 Apartment House ] Commercial ❑Troller Court <br /> Motel ❑Other ........................................ <br /> Number of living..units ..... .... Number of bedrooms ...Z)-----Garbage Grinder ............ Lot Size ...j. :.X... : .......... <br /> Water Supply: Public System and name :---_--___•. _-- ..............-:- ..... ❑ <br /> ......... ...... ------......_........_........ ....-........................Private <br /> I Character of soil to'o depth of 3 feet: Sand 0 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avallable within 208 feet,) <br /> PACKAGE TREATMENT SI_PTIC.TANK{ j Size.................................--.___....•.... .Liquid. Depth........................... <br /> Capacity -------------- ----- Type ----------.......... Material...................... No., Compartments ................. <br /> Distance to nearest: Well "' '."-:. Foundation . . p. <br /> l ------------- ..-•---••-• ----.................. Pro Line ........---•--........ <br /> % <br /> LEACHING LINE [ ] No. of Lines - .:.�...----.__._.._ Length of each lin .._.'.�'�4_.......... Total Length ../ .. ..:..�--.---- s/ <br /> D' Box T filter Material .Depth .Filter Material ............................................. I <br /> Distance to nearest: Well ....45-7.............. Foundation ..................... Property Line ...•.................... <br /> f ... Pra � . <br /> SEEPAGE PIT ( 3 Dept1 f X-IX.1-0----- Diameter :-------..-_--- Number ...A...................... Rock Filled Yes [f No [3 <br /> i Water Table Depth --------------------------------------- ...Rock Size .....---=-------..:.--------•--- <br /> Distance to nearest: Well ---------------__.....................Foundation .................... Prop. Line ...................... . <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ----------------------------------•--------- Iddte ....--__ ....... --............ <br /> SepticTank (Specify Requirements) ---------- ---•--------------- ------------ .............,..........------•---•--•--------------...--- ..................... <br /> Disposal Field (Specify Requirements) ---------------- ----- ------------------....._.........._.._....••-------.................................._.........._........ <br /> i ----------------------------••------•----------------------------.......... _ .._..-----•. .....•••. <br /> ----------------------------------------------------.-.-------------• ------•--------•---------------------..------------------------ -----------------...._..._....------.._..---.._.......... <br /> A (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 San Joaquin <br /> County Ordinances, State'.Lawi,,and,Rules and�Reg'ulations of the San Joaquin Local Health,District. Homs owner or licen- <br /> sed agent signature certifies the following: ... <br /> "I certify that in the performance of the work for L which this permit is issued, I-shall not;employ. any person in such manner <br /> as to become subject to Workman's CompensatioW laws of California. <br /> Signed _._ �._.. =::__ .- - :..__._ -------------- -•------ • ......•. Owner <br /> BY ----- --- ------ ------ ----- ? - itis <br /> z �(if ot, er t n owner) ,. <br /> lt JEOARTMENT USE ONLY <br /> APPLICATION :ACCEPTED BY .......... --------------------------- <br /> DATE---DATE: , <br /> BUILDING PERMIT ISSUED - ------------ DATE <br /> ADDITIONALCOMMENTS ------------- ----------- - ••--------------•--------••-•---•---•--•----- ------ ----------........_..._-.................... .......... ........ <br /> ----------- ----------•---- -----------------------------------------------.....................................-•- .....------------------- <br /> ...................... - ------ ........ <br /> -••--•-•--•-.._...__....._........._..__ ........ -•------•- ------...---------------------------------------------------....................... <br /> --. ---- --- ,- - <br /> Final Inspection b ..----._Date -. � --- .-•------------------- <br /> ... <br /> + EH 13 2tt 1"68 Rev. 5M i SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7)t 3M <br />