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p _ <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 'q <br /> -------------- -------- --------------- --------------- <br /> Permit No. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year from Date Issued <br /> Date Issued _ - --- . <br /> --------------------- ------------------- --------------- <br /> Appiication is hereby made to the San oaquin Local Health Distriet,for a permit to construct and install the Work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules aril°Regulations: <br /> JOB ADDRESS/LOCATION ._ _ ---"� f ------ --- -_ + 't "._CENSUS_TRACT ---- <br /> Owner's Name _ Ph one <br /> Addressi CQ � �j -_ �_f. City -� ��-✓"�= - - ------------------- <br /> --- ------------ -- ,� <br /> Contractor's Name - ------^"=----License Phone <br /> Installation will serve: Residence WApartment House❑ Commercial :❑Trailer Court i❑ <br /> Motel ❑ Other ---- --------------------------------- <br /> Number of living units:__-- Number of bedropmst__ arba a Grinder -__ Lot Size ____'_ h----------------- <br /> i <br /> i <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 <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 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 frfS?//Z_SSize------------------------------------------------ Liquid Depth - ------------------------ <br /> Capacity ------------------ Type ----- -------------- Material-----. ------------- No. Compartments ------•--------------- <br /> 6 <br /> Distance. io nearest: Well ____________________________________Foundatio----------------------- Total Length ---70--______-_________ t- <br /> 'D' Box __ ------ Type Filter Material .I7 ___Depth filter Material ----- _-----____________ ______ <br /> Distance to nearest: Well ----- ----------- <br /> Foundation�__ C>- ____*---- Property Line _____'�_______________ <br /> SEEPAGE PIT [ ' Depth _ _ _,__ ___ Diameter ___ __________ <br /> rNumber Rock Filled Yes No z <br /> Water Table Depth --�----- ---Rock Size ----- <br /> Distance to nearest: Well ----- ------------=------ Foundation __Aa--____-- Prop. Line --�----------____-. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --------------------------.------ ) <br /> R. <br /> Septic Tank (Specify Requirements) ------------------------- ------ ----------------------------;.------- -------- ---------------------------,-.------------ ------------ <br /> ------- <br /> Disposal Field {Specify Requirements) _��: L<� <br /> + -'.� .� -- --- <br /> ------------------------- <br /> - <br /> xz ------- -! - ------------------------------ <br /> 11 <br /> ---------------------_______________•-------.--------------.F----____________________----;-________________----_-_____________:___---._:-,_,-___________________-------_-______________'F______-__--------------- <br /> _ (Draw existing-and--required dddifion 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° ! tare,Laws,'and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> 1 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." <br /> f: Signed ------------ .�-(--- -- ---------- - -----------:�----------- Owner - ,-_ <br /> �� _ <br /> By -------- � '------ �'t -- ---------- Tit! -: � � <br /> (If other than owner) `i <br /> t • I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - <br /> - -------------------- --- ---------------& ------------------------------- DATE -------��-0 ---Z- <br /> BUILDING PERMIT ISSUED . - DATE ------- ---------------- ---------- <br /> ADDITIONALCOMMENTS ------- Z -4--�------------------------------`--------------------- ------------------- --------------------------=----------------I--------- <br /> �. <br /> -------------'�----------------------------------- ------------------------------------------`---- <br /> - ----P ----- ------------------------------------ --------------------------- ------------------- ---------------------------------------------- -------------- ------ <br /> ________________ _________________________L_ --___-__ _-___._________________-______________-___----___-_______-____-___-__--_-__________��_ 4Final, <br /> Inspection by: __�"____ ' <br /> - - - -- - ------------------- --------------•-•--------=-----•------------- ----------Date -- -- ---�------ -------- <br /> SAN'JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />