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FOR OFFICE USE: i <br /> ----------- <br /> a APPLICATION FOk SANITATION PERMIT <br /> ( Permit No: .__-_._r-__- <br /> Complete in Triplicate) .._ 1 <br /> - ------ ------------------------------------- <br /> --------------- This Permit Expires 1 Year From Date Issued <br /> 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 applicati n is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __ __�_- ____ -- - =-------------- -- ---------------.-----=--------------CENSUS TRACT -------------- ------ m , <br /> F 3` Zo1] <br /> Owne ' - m ------ -- -- - ---- -- - ---- ---------------- ------- ---------------------- -------------=------------- -------Phone ---------- - <br /> ------------------------ <br /> Address -_.._.. ----- — - -- City --------- -----,---- ------------------------------ <br /> Contractor's Name K--------I/---- Rwpv--------------------License # --------- ---- - Phone ----------------------------- <br /> Installation will serve: Residence [2 Apartment House❑ Commercial:❑Trailer Court i❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units.-I-------- Number of bedrooms -j--------Garbage Grinder ------------ Lot Size ------------------------ <br /> Water Supply: Public System and name ________________ 4 Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam :R <br /> Hardpan Adobe '❑ Fill Material ------------ If yes, type -_-__-_--_____-__--_____ <br /> (Pl'ot 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) <br /> VJ j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Size------------------------------------------------ Liquid Depth -------------------------- r� <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' <br /> ___-_-__'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------__---------- f <br /> Distance to nearest: Well ________________________ Foundation --------- Property Line ____--_____..____-_-___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---_------------------------ 'Rock Filled Yes ❑ No C <br /> Water Table Depth --------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---.------------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) - - ---- ' �L � '? <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------s------------------------ <br /> ----------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- <br /> (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: <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 /> asto b ome-subject to Workman's Compensation laws of California." <br /> Sign" e J - .. -------------- Owner <br /> By ----------- --- ----------------------------------------------------------- Title ------------------------------------------------------------------------ <br /> (If other than owner) I <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED aY - - - - ------------------------------------------------------------------ DATE -�Q'Y�`' -tt------------- ---- <br /> BUILDINGPERMIT ISSUED -------- ---------------------------------------------------------- --------------------------------------DATE --------------------------- ---------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- - --------- --- <br /> ---- --- ------- <br /> -- - ---- ---------- <br /> ----------- - ----yam_ tom,,- -- <br /> 1 ----- -- --- 7- <br /> - --- --- -- -- <br /> inol Ins ection ---.Date --.------------------------------ <br /> ' - -_-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT '-7 d <br /> I <br /> E. H. 9 1-'68 Rev. 5M <br />