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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> [Complete inTriplicatel <br /> - ,. - Date Issue -1/7 <br /> This Permit Expires 1 Year From Date issued <br /> ----------------------------------------- <br /> construct and <br /> l the work herein <br /> Application is hereby made isothe madeain co plln Local ia ce withealth Counttytrict for a Ordinance No. 49rmit oand existing Rulestalnd Regulations: <br /> described. This applica# r <br /> CENSUS TRACT -------- -•-------•- <br /> JOB ADDRESS/LOCAfTT4 N -- -` --- �-f_--- f <br /> Owner's Name --------- Ir <br /> Phone <br /> �- . `° - e ------------------------------------ <br /> Address ---------- - t <br /> ---. Ci ------------------------------•----•----- <br /> - -- --------- <br /> ^ = License #Af hone <br /> Contractor's Name ------- - - -� �/�-�--c <br /> Instal will serve: Residence Apartment House Commercial :❑Trailer Court <br /> Motel ❑Other ------------------------- ---------•-------- <br /> Number of living units:----- ------ Number of bedrooms -3-------Garba.ge Grinders-- Lot Size,0/1--x---' <br /> i .. � - -----------------------------Private +�� <br /> --- <br /> Water Supply:Public System an name ------------------------------------------------------------ •--------•- - - El of soil to a depth of 3 feet: Sand'❑ Silt❑ ' Clay Peat F] Sandy Loam .❑ Clay.Loam <br /> Hardpan ❑ Adobe: ill Material -/V -- if yes,type --------------- ------- <br /> f [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] <br /> is available within 200 feet,) <br /> I NEW INSTALLATION: (No septic tank or seepage pit permitted <br /> if public sewerLiquid DepIts <br /> th <br /> I PACKAGE TREATMENT [ ] SEPTIC TANK [ ] <br /> j Capacity ------------------ - Type -------------------- Material--------- --------- No. Compartments-•----------------=•--- <br /> Distance to nearest: Well -"--------- <br /> I ------------------- -----Foundation ---------------------- Prop. Line •--•---------=------- <br /> l LEACHING LINE [ ] No' of Lines -------------- Length of each line----------------------------___ Total Length <br /> 'D' Box -------- --- Type Filter Material --------------------Depth Filter Material <br /> Distance to-nearest: Well -__-_----_--- -- .- <br /> --------- --------_---•- <br /> : --_____- _------- Foundation -------------------- -- Property Line -------- -------•-- <br /> ..-_-`_- <br /> o <br /> SEEPAGE PIT [ ] Depth ------ ---------- Diameter Number -__.----------------------- Rock Filled Yes ❑ <br /> Water Table Depth Rock Size -_---------------------- <br /> ------------------------------- ------- <br /> Distance to nearest: Well ___-__"------------------------- <br /> Youndation Prop. Line ------------------ --- <br /> REPAIR/ADDITION(Prev. Sanitation Permit=# --------------------------------------------------------------------- <br /> � - D` <br /> ate ------- -------------------------- <br /> --------------------------- <br /> --------------------- <br /> ----------- <br /> Septic Tank(SpecifY Requirements) ----=-------------- ------------------ I- <br /> ------------------X <br /> Disposal Field (Specify Requirements) -_------ " <br /> - <br /> / l ---- -- ------ - 6- -- ----------------------------------------------------------- = <br /> --------------------------- <br /> - -------- - -- =------------------------- ----------------------------------------------------------- -------------- <br /> ------------- <br /> ---------- <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 Iicen- <br /> sed agents signature certifies the following: <br /> Ffor which this permit is issued, 1 shall not employ any person in such manner <br /> "I certify that in the performance of the work <br /> as to become subject to Workman's Compensation-laws of California." <br /> .' <br /> Owner <br /> Signed ----------------------------------------- � <br /> Title - ���.""""--��� <br /> (I they than owner} <br /> FOR DEPAitTMENT USE ONLY <br /> ��--------------- <br /> �=--------- ----------•---..DATE --------�-------- ----•---- <br /> APPLICATION ACCEPTED BY ------- --- ------ - -- ----------------------------------------- <br /> ----�.> <br /> BUILDING PERMIT ISSUED --------------------------------- r <br /> *' DATE ------ - ------------ ---- ---------------- <br /> ADDITIONAL COMMENTS �j'�2 -L9----0 �1Ir__ - = - <br /> -------------- <br /> - --------------------------------------------------------------- <br /> U _ ---- --------------------------------------------------- ----- -Date ------- ----- ----- - - -- --- <br /> Final Inspection b - --- -- ----- -- ------- - �- ----------------- <br /> AN JOA IN LOCAL HEALTH DISTRICT <br /> 1t <br /> E. H. 9 1='68 Rev. 5M <br />