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FOR OFFICE USE: <br />C-- _ PPLICATION FOR SANITATION PE <br />-----------a---- Permit <br />(Complete in Triplicate[ '} <br />----------=------------------•------------------------ - <br />--------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br />Date Issuedt <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br />describ d. Thapplication is ade in com [lance with County Ordinance No. 549 and a istin Rules, a ulations: <br />JOB ADDRE /LO ION . - -- • ' . .... . ....... �f�.... ---..... CENSUS TRACT .......................... <br />-- ---•••--- -- -- - <br />Owner's Name - - -- ------- -----------Phone ® .._... <br />44 /f <br />Address=-Qr.- 1- i----------------------------•-------------. City <br />Contractor's Name .-•----- .- --- <br />- - ------------------------------ -------License #f l%-------- Phone --- (!Q - <br />Installation will serve: Residence E] Apartment House, Commercial f7Trailer Court iE1 <br />Motel ❑ Other ............................................ <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 'Q Silt ❑ Clay _D ,Peat ❑ Sandy Loam Clay Loam <br />Hardpan Adobe Q Fill Material ------------ If yes, type ............................ <br />(Plot plan, showing size of lot, location of+ system in relation toiwells, buildings, etc. must be placed on reverse side.) <br />to! <br />wells, <br />(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br />f v ld <br />PACKAGE TREATMENT [ ] SEPTIC TANK <br />-•- Size...... X. 9 ....................... Liquid Depth ..,>..7_.......--...... <br />-e4!iv <br />Capacity �,t-TTYPe _ __ __ __ _______ Material.. No. Compartments .._........ <br />Distance to nearest: Well (iJ:% ----------------- Foundation _/_eZr........ Prop. Line __._ _----------- <br />LEACHINGLINE,._ No. of .-Lines. , <br />_- .Z". -.-_- -Length of each line._._,lCV ®-....--.... Total Length -_ -._ ..f......... <br />D' Box .._ _- Type Filter Material :.... _. _ -.._Depth Filter Material ....� .... ............................ <br />r _._ �' <br />Distance to nearest: Well .f_TM..__._ Fo—uridation --- I-0 Property Line .. .................. <br />SEEPAGE PIT [) Depth_; ._....... It ....... - Diameter Number ---------- -I ............... Rock Filled Yes 0 No fl <br />Water Table Depth --------------------------------------------- ... Rock Size ................................ <br />, <br />,,,,,-,Distance to nearest: Well ---------------------------------------- Foundation .................... Prop. Line ...................... <br />REPAIR/ADDITION-(Prev. Sanitation Permit #............................................ Date .................................. <br />SepticTank (Specify lequirements) ---------------•------------------------------------------------------------------------------------•------•----- ----------------------•---- <br />DisposalField (Specify Requirements)------------------------------------------•-------•------------------•----•------------.....--•--------------- ...................... <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 manner <br />as to become subject to Workman's Compensation laws of California." <br />Signed-------------- ------------- - ........... --- ----- •.................................. Owner <br />BYf ------- ------------------------------ Title ------ <br />(if other owner) <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY ---- ------------------------------------ DATE ... �j--------------- <br />BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------------DATE------_-------------- ------------------- <br />ADDITIONAL COMMENTS <br />-------------------------------------- <br />----------------- -------------------------------------------------------------------------------------------- <br />---------------------------------------------------------------------------------------------------------------- ----------------------------------------- ------------------------------------- <br />--------------------------------------------- - - -------- <br />Final Inspection by: --- - Date <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />E. H. 9 1-'68 Rev. 5M <br />