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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> +� �--------------- (Complete in Triplicate) Permit No. <br /> = <br /> --------- --------------------------------- <br /> -------------- This Permit Expires 1 Year From bate Issued <br /> Date Issued _�-=-3-0=7 <br /> -------------------------------------- <br /> __--------------_ <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 compliances with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------------------- -------CENSUS TRACT -------------------------- <br /> Owner's Nameft . `-- �an� s -------------------------------- ---- Phone --� <br /> �y r- a e <br /> Address _./ + � /_ / City L_l��'PIVG --rj / <br /> _ / ((( -- <br /> Contractor's Name -------Y----- ------- - 1� � �!' �1__`��------------------------------License yL / Phone . --------------- <br /> Installation <br /> -`Q/ <br /> Installation will serve: Residence [+Apartment House,❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units.--- ------ Number of bedrooms _i ---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 <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,) <br /> PACKAGE TREATMENT [ SEPTIC TANK'f I Size--------------------------------------- Liquid Depth ------------.-.--------.-- <br /> Capacity -------------------- Type --------- ---------- terial----------------- --- No. Compartments ---------------------- <br /> Distance to nearest: Well --------------------- --------------Foundaf n ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length each line--------- ------------------ Total Length ------ ----------_---- <br /> 'D' Box ------------ Type Filter Materi --------------------De th Filter Material -------------------------------------------- <br /> Distance to nearest: Well --- ------------- Foundat' n ------------------------ Property Line -----..-.-__---._.... <br /> SEEPAGE PIT [ ] Depth --------- - -------- Diamete -----------._.. Nu er --------------- ------------ Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ---------- ---------------------------- --------Rock Size -------------------------------- <br /> Distance to nearest: Wel -------------------------- ------------Foundation -------------------- Prop. Line .-..-__-..--.-...._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------- --- ----------- Date ----------------—---------------) <br /> Septic Tank (Specify Requirements) --------- -------------------------- --------------------------------------------- -------------------------- <br /> „ / f, i <br /> Disposal Field (S ecify Requirements) /Y_- 1 f Q.--- ---�'��« - - f <br /> --------rte -----------i4;f,011 ----------- <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 manne+- <br /> as to become subject to Work n's Compensation laws of California." <br /> Signed - --- ---- ----- ---------- -----A- ----- _ Owner <br /> BY ---- ----------------------- Title ---------------------------------- ------------------------------------- <br /> r <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ------ �Q.�"4- -------- <br /> DATE ��c,� <br /> BUILDINGPERMIT ISSUED ------------------------ ------------------------------------------------------------------ --------------DATE ----------------------------------- ------ <br /> ADDITIONALCOMMENTS ------------------------------------------ - --------------------------------------------- --------- -------- ------------------ <br /> ----------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------- - ---- f----- - - <br /> ----- -- ---- r- ---- <br /> Final Inspection by Date r�� h ' 1�r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />