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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> is- -�l�`. ----------- <br /> (Complete-: <br /> ? Permit No: . `v _� <br /> in Triplicate) <br /> �I Date Issued _-//=/v--6) <br /> - --------- - ------_---_---------------_----_--__h-- This.Perm it Expires 1 Year From Date Issued <br /> �k <br /> Application is hereby made"to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This appiication is made in complia ce-with County Ordin ce o. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LO ON -- - ----------- -- ---o--f- CENSUS TRACT <br /> Owner's Name = ------------------------------------------------ ---- -Phone ----------------------------------- <br /> Address -------- ----- �---_-'__-- --- --- --------•------------- ---------------------------. City ------------------------------------------------------------------•-•------- <br /> -- --------- -------License # ---------.--------------- Phone ------------------ <br /> Contractor's Name - ---- - - -- ------------ ------------------------- - - ----------- <br /> Installation will serve: Res idence*-)(partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other --------------------------- --------------- // <br /> Number of living units------- Number of bedroom -_ <br /> s 3------Garbage Grinder -e- Lot Size _-���--�C� _________________ _ <br /> it <br /> Water Supply: Public System and name -------------------------- --------------------------------------------------------- -------------Private ❑ <br /> Character of soil to a depth'of 3 feet: Sand b Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ <br /> r Hardpan ❑ Adobe ill Material ------------ If yes,type ____________________________ <br /> k 1 <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 [ ] Size------------------------------------------ ----- Liquid Depth --------------------,----- <br /> Capacity ---------- --------- Type -------------------- Material---------------------- No. Compartments -----------------= <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------.,------ <br /> LEACHING LINE ) ] NoI of Lines ------------------------ Length of each line---------------------------- Total Length ------ ------------- <br /> 'D'i!Box --------- -- Type Filter Material --------------------Depth Filter Material •---------------------------------------• <br /> Distance to nearest: Well ________________________ Foundation ----------------- ------ Property Line, _________-_--_-___._._.. <br /> it <br /> SEEPAGE,PIT ] Depth ------ ------------- Diameter ---------------- Number -------------------- ------- Rock Filled Yes '❑ No <br /> WalterTable Depth -----------------------------------------------Rock Size ---------------- --------------- <br /> =:,11 <br /> Distance to nearest: Well ----------------------------------- ----Foundation -------------------- Prop. Line ---------------------- <br /> II <br /> REPAIR/ADDITION(Prev, S�`nitation Permit# -------- ----------------------------- - Date ---------------------------------- <br /> TS <br /> Disposal Field (Specify Requirements) ------ �� -...------------------- <br /> Septic Tank (Specify Requirements) ------------ ------------ �------ ------- ------- - --- <br /> E --------------------------------------------�____________- ---____--__-______.--_--__________-______---__-.________-_________.._-------_______------__________--------_________..__-___________-_________ <br />' ---------------------------- -' a <br /> ______---_-_________------______________ __-.__-__--__-----_______---_----_______--_----_-________------________-_--________-_----___ <br /> I� (Draw existing and required addition on reverse side) <br /> I hereby certify that I hall 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 "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 --------------------- -- -------I`----------------------------------------------------------------.Owner <br /> By ---------------------------------------IL---------------------------------- Title ------------------------------------------- - -------------------------- <br /> (If other than1owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. = DATE �7 1��'� G�- <br /> BUILDINGPERMIT ISSUED'�------------------------ -----------------------------------------------------------------=--------------DATE ---------- ----------------------------•- <br />' ADDITIONAL COMMENTS - ----------------------------------------------------------------------------------------------------- --------------- -------=-------- ----------- <br /> ------------------- ------------------------ii------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------ <br /> -------------- <br /> ----------------------------- <br /> Final Inspection by. - I� <br /> -- --------------- --- -- - ----------------------------------------Date ----•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT.. <br /> E. H. 9 1-'68 Rev. 5M..1 <br />