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FOR OFFICE USE: I! APPLICATION FOR SANITATION PERMIT S <br /> --------------------- ---------------- - ----------- '--- (Complete in Triplicate) Permit No. --7`--- ---------- <br /> ii <br /> ---------------------- <br /> ------ - ------------------- ----------- Expires 1 Year From bate IssuedDate Issued <br /> ----__-._ This Permit i--- � <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 Iis made in compliance with County Ordinance No. 549 and existing Rules and Regulations: i <br /> JOB ADDRESS/LOCATION ��f �J J"`____ -1 Cr.r..�4 7� ''-- - ,� CENSUS TRACT <br /> ---- f -------Phone _- C ----------- <br /> Owner's Name � ii- ---�r---��-r-- --- -----------------------------------•-----Cit--------- --� <br /> a 1C1_ -�' s/1�CX��/ A v �3��C <br /> Y <br /> Address --------:A- --- `'F - Y <br /> Contractor's Name ----- .�_;I I� �/ - License # �=r`! -�'---- Phone -'- ��f�---- <br /> Installation will serve: Residence ❑Apartment House-E] Commercial :❑Trailer Court ;❑ <br /> ii Motel ❑ Other �}'�t�--rl �r'l►'L_: <br /> ---------� <br /> Number of living units:.________ Number of bedrooms ________Garbage Grinder:'_____ Lot Size _____ _F___---______ <br /> Water Supply: Public System and name ---------------------------------•----------------------------------------•-•------------------ ---------------Private <br /> Character of soil to a depth`,of 3 feet: Sand Silt❑ Clay E] Peat❑ Sandy Loam E] Clay Loam :❑ <br /> li Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- , 1 <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,) �1 <br /> PACKAGE TREATMENT [ ]h SEPTIC TANK [ ] Size-------------`Z_-'--- - ---�---- Liquid Depth ---- ---------•-------- <br /> Ca �' <br /> r -•----------=---- <br /> pacity .�-�-1_-t-------- Type •�__-'`-s._�--,I---"-/Material---C-�'--�1--�- No. Compartments aa <br /> Distance to nearest: Well -------� -`________.--------Foundation _±_f.�_----------- Prop. Line ___________________• IJa <br /> LEACHING LINE [ j No. of Lines---------_=_l --------- .Length of each line----------r_--'- __ ______ Total Length ____ <br /> D' Box ___�_____ Type Filter Material _ _____ _=__Depth Filter Material ----Z­U........___ <br /> I <br /> Distance to nearest: Well ----- ___ Foundation -----1LO-1 Property Line -----:--_ <br /> SEEPAGE PIT [ ) Depth ____ _____________ Diameter! Number _.-------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth <br /> ----------- <br /> -------------- Rock Size ; <br /> Dis I <br /> tante to nearest: Well ----------------------------------------Foundation ------------------ -- Prop. Line --------•------------- ; <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- <br /> i - <br /> Date ________--__-____________-___----- <br /> SePtic Tank (Specify Requirements) ____________________- --------------------------------------------------------------------=--------1------- ---------_ <br /> -------------------- <br /> Disposal Field (Specify.,Requirements) ---------••- -- = ------------------- <br /> f r ............ <br /> I� ---------------------------- ----------------------------------- = -- --- --------------------------------------------------------------------- <br /> { <br />[ - ____________________________________________________________________ <br /> IF (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 Laws, and Rules and Regulations of the San-Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: t <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's-Comp-ensati.on•laws of California." ,_ '• __ -.a <br /> /� i� �' �' -- J I r---------- --------- Owner <br /> Signed ------��----,� � ]_: <br /> ---- ------ <br /> ---- Title ------------- ---------- <br /> l <br /> / r r ����__-____�'------------------- <br /> (If other than',owner),r_' <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION zACCEPTED118Y '• __ DATE------- .�/ ----------------- <br /> r --- <br /> BUILDING PERMIT iSSUEDi-1 � = �r*-'- ---------- DATE <br /> I <br /> i ?- t------------- -'- --------------- <br /> ADDITIONAL COMMENTS ---- - ------------------------------ ------------------ <br /> ----------------------------------------- <br /> ti. . -------------- <br /> ii' <br /> -------------------------------------------------------- --------- ------------------- <br /> --------------------- - - [�,,.,,�-------------- L. <br /> Final Inspection by: -----,-'---�--- ---------------------- ---------------------------------------------- -- --- --- -(.1/�(_---Date <br /> �a� �� .... <br /> a SAN JOAQUIN LOCAL HEALTH RICT <br /> II <br /> E. H. 9 1-'68 Rev. 5M11 J <br />