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FOR OFFICE USE: 4" <br /> y APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. -_- <br /> 6----- . <br /> ---------------------------------------------------------- <br /> ' Date Issued <br /> ------------------------------_____--___-__-__---_-- This Permit Expires 1 Year Oram„Date Issued , <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 application is made in compliance with'County,Ordinance-No. 549 and existing Rules and Regulations: <br /> e <br /> JOB ADDRESS/LOCATIO _ __ ' -- ---------------------CENSUS TRACT --------------.----------- <br /> V........ <br /> Owner's Name ---------- -- ---------------------” - -------- ------- ------Phone L_ <br /> - - <br /> Address - -------t - �� `------ ----- City' i <br /> _ ------------ <br /> [7DSl� Phone <br /> Contractor's Name ------ - _ - ....... <br /> --- -,�--��----------------- --License #�--- -: - - ------ ----- <br /> Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court C] <br /> s Motel ❑ Other -------------------------------------------- <br /> Number of living units:---(__------ Number of bedrooms ______:Garbage Grinder --.--------- Lot Size ____F _ ._______________ <br /> Water Supply: Public System and name --------------------------------------------------- -----------------------------------------------------------Private ❑ <br /> Character of soil to afdepth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ F <br /> [ Hardpan ❑ Adobe ❑ Fill Material =: --. If yes,type ---------------------------- <br /> (Plot <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 arseepage,p-R-perm`itted if'p�blic sewer is available within 200 feet,) E <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size___ !------------------.---------------------- Liquid Depth -------------------------- <br /> 00 <br /> J Capacity -------------------- Type -------------'------ Material--------------.-------- No. Compartments ------------ - 0 <br /> • i i. --,.� . 1 <br /> I '-Di"fan'ce to nearest: Welles__ _- tom- --_=Foundation ---------------------- Prop. Line ______________________ <br /> LEACHING LINE { ] No. of Lines ____i___________________ Length of each line----------------------------- Total Length ----------- <br /> D' Box ------ <br /> ' � ; I7ype Filter Material --------------------Depth Fitter Material -------------------------------. ..--------- <br /> V Distance to nearest: Well ________________________ Foundation -------------------- ---- -Property Line -.--______________._____ / <br /> f i 1 <br /> SEEPAGE PIT [ ] t Depth -- �� _ '=" Number ____-___-____-_-_ __ Rock Filled Yes i❑ <br /> t � , ° - Diameter-�,��::�==--=- { - ---- ❑ No <br /> Water Table Depth ---------------------------------------\----------RockSize ----------------------------•--- <br /> A Distance to nearest: Well ----------------------------------------Foun;dation ------------------7- Prop. Line --------- ------------ F <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________________ Date __________________________________} <br /> Septic Tank (Specify.Requirements) - ---i------------ - - ---------- --- -- - ---------------- ------- <br /> I� <br /> Disposal Field (Specify Requirements) - = ==- < .5 = = ------------------ - ------------ <br /> !/x <br /> _______________________________r_______.__________ _____________________-----------------------------___-_____ ___________-_-__ ----------------------------------------------------------- <br /> ' ;(Draw existing and required addition on reverse side) <br /> I hereby certify that F have prepared this application and that the work'�will4 bek done-in-,accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Locdi"Health*District. Home owner or licen- <br /> sed agents signature certifies the following: v <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 /> J`fir_,�• <br /> By -------------- ----------- -- ------- -- -------- ---- Title ----A!!!4- - -------------------------------------- ------------ <br /> (If oth an owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ ___ __ ________1-4 --------------------_-- -----------------------------------. DATE __ - - - -------------------- <br /> BUILDING PERMIT--ISSUED---------------'----------'------------------------------------------------------------------ ----- --------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------'--------------------------------------------------------------------------------------------------------=-------------------------------------- <br /> Final Inspection by `-'� -----------------------------------------------------------------------Date - -_ ftp- ---------- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />