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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------ ------------- ----- - Permit No. 2�_-- <br /> (Complete in Triplicate) <br /> --------------------------- This Permit Expires 1 Year From Date / <br /> Date Issued _�I-/_ ,17 <br /> ___ __ <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 with County Ordinance No. 349 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._ ._ "- /----- _-- - -------CENSUS TRACT :' . �---------------- <br /> yy��.�� �---- <br /> Owner's Name ''F ---------------- = Phone <br /> ---- ----- - <br /> ----------------------------------- <br /> Address --- 1 F I�� '"p�r , ,""�`` -------------------------------•----. City -- - ----- --------- ----------------------------------------- <br /> Contractor's Name - �'c...`.... ---------------------------------------------------------License # ------------------------ Phone _-------------------•-_--•-- <br /> Installation will serve: Residence ❑ Apartment House,❑ Commercial ❑Trailer Cmrrt <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size-------------------------- <br /> Water Supply: Public System and name ----------------------- <br /> ------------------- - -1 <br /> -------------------- - ----------------------• ----------------------------•---------Privat e-M <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam-+H Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type _.______-__________________ <br /> (Plat 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 <br /> .. -//y .)D_--__�____________________ Liquid Depth 41-t-------------------------- <br /> Capacity <br /> ----_.------------- �1 <br /> Capacity IA-" ------ Type_- _--- Material--ls�^"r____-._-- .No. Compartments ?'"--------------•--- <br /> r <br /> Distance to nearest: Well -_ ____' -------------_--------Foundation -10_ ------------- Prop. Line ________--------.___ <br /> LEACHING LINE �,�.] No. of Lines __ ----------------- Length of each line------ra---------------- Total Length Ae----------.______-_ <br /> 'D' Box! '___--.- Type Filter MaterialA1'�____--______Depth Filter Material _ _ ----------_____________ __________ <br /> 1 <br /> Distance to nearest: Well -__ - - -------- Foundation _/10"i----------- Property Line ____________________ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth --------------------------------------------_.Rock Size -------------------------------- <br /> Distance to nearest: Well _______________________________________Foundation ----- -------------- Prop. Line ______-:_.-_____..__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•.---- ------------------------------ Date -----------------------.----------j <br /> SepticTank (Specify Requirements) - ---------------------------------------------------------------------------------------------------------------------------------------•-- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------I-------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- <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: r <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 /> as to become subject to Workman's Compensation laws of California." <br /> Signe ------------------------- --------------------- --------------------------------------- Owner <br /> RUN-- - <br /> 8Y ---- - - - - - - ------ --------------- <br /> ----------------------------------- -Title - -- ----- ----------------------------------- ------ ----------------- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �,/�' ;r 'AZ------------------------------------------------------- ------- DATE --------- <br /> BUILDINGPERMIT ISSUED ------------------------------------- --------------------------------------------------------------------DATE ------- ------------------ ---------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------- -------------- ------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------- <br /> ------------------------------------ --- <br /> - ------------------------------------------------------------------- ------ -- - ---- ! <br /> Final Inspection by. ---------------------------------------Datef'/u �_ <- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />