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FOR OFFICE USE: <br /> ry APPLICATION FOR SANITATION PERMIT <br /> --- ----------------------- F <br /> Permit No, <br /> (Complete in Triplicate) <br /> (/ I Date Issued <br /> ------------------------ <br /> Application <br /> ' This Permit Expires 1 Year From Date Issued <br /> :i <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ ------ - --- _..___.. ....... ............CENSUS,\T!'ZACT=>_._____.__._______-___ <br /> - ---- - - - - ---------- <br /> t �+ <br /> Owner's Name -------------- --- ------ ----------------- ----------------_-Phone <br /> Address city <br /> ----------- . Z.�� t # '� ...... ' <br /> - ---- -- --- ----------------- - -- -------- -- t'�-------- <br /> Contractor's Name --------- ---------- -------------- ---- ----------- -.License #L ------- Phone <br /> Installation will serve: Resid�ennce�Ap tr�ien�_.House ❑ Commercial :❑Trailer Court ❑ <br /> Motel ❑ Other _7:�--- `- _�-------------------- <br /> ------ / / <br /> r !Vi <br /> Number of living units:----- Number of bedrooms _. _ Garbage Grinde�______ Lot Size /_ __. _____________ <br /> Water Supply: Public System and name ------------------- --•------------------------------------/__ ----- <br /> '---------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Of Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ -Adobe Fill Mdterial i________ If yes, type --------..__-___._________ <br /> (Plot plan, showing size of lot, location of systein1n:rel.6tion t6 wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permifficid'if"public s6 wer is available within 200 feet,) 4 <br /> k ` 1 , <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------- Liquid Depth ______._____-- <br /> �_,.- 1 Ya16 <br /> Capacity ---- ------------- Type ____________________ Materia!__ «: _.------____-- No. Compartments ---------:----_.-:-- <br /> Distance to nearest: XW1 ----------------=-----_.---___=-_.•Foundation ---------------------- Prop. Line --------- --------- _ <br /> LEACHING LINE [ ] N i. of Lines ------------- --------- Length of each line.- ------------------------ Total Length ------. .................... <br /> 'D'� Box ------------ Type Filter Material ------------------ 'Dep h Filter Material -------------------------------------------- <br /> Distance to'nearest: Well ______________________ Foundation !-----------°------------ Property Line. _______-__________-_____ <br /> SEEPAGE PIT [ ] Depth _----------------- Diameter ---------------- Number _r ---- Rock Filled Yes ❑ No I❑ <br /> F _f <br /> Water Table Depth ---I--------------------------- ---- ---R6ek`Size -------------------------------- <br /> [ i <br /> Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line _________-_-____-_____ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ------ ---------------- ---- ------------ Date ------ -------------- -_----- ) <br /> Septic Tank (Specify Regvirements).__'- -.t_ � � 1- ---------------------- <br /> Disposal Field (Specify Requirements) -------- ------.5;�3 5 ---- --- I------------------------ ------ _ <br /> I <br /> ---------------------------------------------------------- -------------- ---- ------------------------------------- <br /> i s s <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I hal 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 /> as to become subject to Workman's Compensation laws of California." r <br /> • <br /> Signed .�..- �.--.-�.-,-_-.�._ :_..�.�,�.---.. .�, v..._ <br /> ------------- -------------- --------- --- -- <br /> - ------- - - -- -- ------------------------- Owner � <br /> Title .___i <br /> (I of er t a owner) �,-f _ <br /> F EPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED BY .---- ----------------------------------------------------------- DATE _17/77/20----------------------- <br /> BUILDING PERMIT ISSUED ------ - ----- - <br /> --- ---------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----- ------- ------------ ---------------------------------------------------------------------------------------- <br /> ------------- ----------- ------ ------------------------------------------------------------------------------------ a <br /> ---- - ------------------------- ----------------------------------------- -------- ---------------------------------- <br /> ----------•-------------------------------- ------ ------- - ------- --------------------------------------- -------------------------------------------------------------------;------- <br /> Final Inspection by: ------ :- --------------------------------------------------------------Date --- - ------------- <br /> /I N AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1- 68 R . 5M <br /> a <br />