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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - ---------------------- --------------------- Permit No. 7 7 <br /> (Complete in Triplicate) <br /> ------------------------------------------------ <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> --------------------------------------------------------- <br /> Application is hereby made to the San Joaquin Local Health District for:a per to construct and install the work herein <br /> described. This application is made in compliance wit County.Ordinance No. 549 and existing Rules and Regulations. <br /> V J6 <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION - -----------Phone ------------- <br /> -- -------------------- <br /> Owner's Name <br /> Address ------------------------------------- <br /> Contractor's Name /tom^^- ��� "" ?G" � - .License #[- 3 >' Phone __.. - <br /> Installation will serve: Residence ❑ Apartment House-E] Commercial:❑Trailer Court ;❑ <br /> Motel ❑Other ------ <br /> Number <br /> ----Number of living units------------- Number of bedrooms ------------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 plan, showing size of lot, location of system in relation to wells, buildings, etc. must be plated on reverse side.) (f� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> � <br /> � k 5------------- Liquid Depth . "-.------- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size____'___�_��__" _-___ -------- <br /> n� d <br /> Capacity��_____ 'Type �- Material No. Compartments ---------• <br /> / Distance to nearest: Well -----------1-o-02------------Foundation/ ........... Prop.Prop. Line ----5--------------- <br /> d <br /> LEACHING LINE ] No. of Lines ___.__c ---------- Length of each line------�a------------- <br /> Total Length ,_1 U.,__--------...... <br /> 'D' Box -----/-..... Type Filter Material ------i5!__Z-----Depth Filter Material -------- ____-__ -_ _ <br /> Distance to nearest:,Well -----j_42_�1_�_____-- Foundation __: --�?-----____-- Property Line ------------------•=•--- <br /> Di,stance s 1 u <br /> SEEPAGE PIT [ Depth _____ _________M Diameter ___ ______. Number --------'� Rock Filled Yes, No <br /> �-- Water Table Deptli ------------------ ---------------------Rock Size 3r <br /> ` Distance to nearest: Weil ___-.____-!S-'----------------------Foundation ____- -a_____.____ Prop. Line _...______......_____. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------- ------------------------------------------------------------•--------•----------------------------- <br /> 4 Disposal Field (Specify Requirements) -------------------------------------------------------------------------------- --------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 Sart 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 /> ' <br /> ollowing: <br /> j "1 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." <br /> Signed -------------------------------- CD Owner <br /> -- - - --------- <br /> BY -------- •----------------- -- Title - -----.-r '------------------------------------ <br /> (If other than owner) <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .__. _ -. rte <br /> DATE _. .' _o4 --Z_7� <br /> BUILDING PERMIT ISSUED _------------------- --------------------------- <br /> --------------------- -------------------------------DATE -------------------- ----- -----------•--- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------- -------------------- ----------------- <br /> ------ ------------------------------ ------------------------------------------------------------------------------------ -------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------- <br /> - <br /> ---------------------------------------------- - -------- , <br /> ---=------- <br /> Final Inspection bY: -------- �`£ �rc�L � Date -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />