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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - . <br /> ----- -------- Permit No. - - <br /> �_�_ _ <br /> n ��, f�� (Complete in Triplicate} <br /> ---------- <br /> Date Issued <br /> -- ----------------------------- ------- __-_--,--__- This Permit Expires 7 Year From 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 /> Of <br /> J,OB'ADDRESS/LOCATION .-----------:ff----6---�-�-------//.-sf��t�P------ -- - - ---r------ <br /> --- ---------CENSUS TRACT --------------- -•---•---- <br /> Owner's Name? re!'('�"----.�-6V .9 --- ----- ----------Phone <br /> _ ----------- <br /> Address --------- ------------ --------------------------------------- --=•------'==------`-----`City ------- - - ---�-------�------------------•--------------- <br /> Contractor's Name a _ ---- <br /> -------_ ---.License # -- Phone -. -- d <br /> Installation will.serve: Residence [gApartment House,❑ Commercial :❑Trailer Court i❑ <br /> rAGel ❑Other --------------------------------------- -- , <br /> Number of living units:._- ------ Number of bedrooms _____Garbage Grinder FLot Size _-- <br /> Water Su - w` <br /> ppY� Y � ----------------------------- - -- - - -- -----•----•-- -----------�----=--=---------Private ❑ <br /> 1 Public System and name __ -_- - -----_ - <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> x <br /> Hardpan E) Ado6e Fill Material __- if yes, type ____- ____._ <br /> (PI'ot plan, showing size'of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) p, <br /> NEW INSTALLATION: (No septic.ta.nk or seepage pit permitted if public sewer is available within 200 feet,) N <br /> PACKAGE TREATMENT [ ] SEPTICjTANK{ J Size-_-_____________ ___ <br /> - --------------------------- Liquid Depth -------------------------- <br /> Capacity ----------- -------- Type -------------------- Material---------------------- No. Compartments ------ -:---- <br /> Ilk <br /> ' Foundation ------------------ Pro Line •------------F-------- , <br /> Distance to, nearest: Well ------------------------------- Foundation --- p. <br /> . f <br /> LEACHING LINT= jJ No. of Lines /__� '-_____.__ Length of each line_*-_�_ �-�_____ Total Length ,__- _�.............. <br /> 'D', Box ----l_-.-- "Type Filter Material __-___�_��____Depth Fitter Material ________� ________________s-.-• <br /> ' Distance to-nearest: Well ------------------------- Foundation ------ .... Property Line --_ID_1....... <br /> v <br /> S ST [ ] Depth _-__ -40) Diameter (�,rj°1 ` Number ---------- __-------------- Rock. Filled YesNo <br /> Water Table Depfih -----------q-,O--7----------- �f <br /> Rock Size -------------- <br /> Distance to nearest: Well _____-' Foundation _._Zd______ Prop. Line _____ ._.......__ <br /> J <br /> REPAIR/ADDITION(Prev. Sanitation Permit F# -------------------------------------------- Date ---------------------------------- <br /> Se <br /> _______.-_--_.__________________- <br /> r <br /> Septic Tank (Specify Requirements) ---- _ ---------�-- -�---- ------------ -------- ----- <br /> Disposal Field (Specify Requirements) ------------_,!_�--•-- ---- <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 Regulcitions 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 /> ---------- ------------ <br /> BY --- ----- -------- Title _ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . -------- ----=--------------------- ------------- DATE - 43-------- •.. <br /> BUILDING PERMIT ISSUED --------------------- --------------------------- DATE -------------•------------------------ <br /> ADDITIONALCOMMENTS ------- ---- -------- ------------------------------------------- ------ ---- ----------------------------- ----------- ---------------------------------- <br /> ------ ------------------ ------------------------------------------------------------------------------=------------------------------------------------------ ----------------------------------------- <br /> -------------------------------- --------------- <br /> --- ------- --- ---- ----------------------------------------------------------------------------------------------------- <br /> ---=--------------- � ----- -- ---------- <br /> --------------------- --------- <br /> Final inspection by: 7 --------.Date Z <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . u <br /> E. H. 9 1-'68 Rev. 5M <br />