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- FOR OFFICE USE: n . <br /> .. -APPLICATION FOR SANITATION PERMIT' / <br /> Permit No..,4-.f�. - Z <br /> - s .� (Complete in Triplicate) - - --mow - <br /> . - - <br /> This Permit Expires I Year From Date issued 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 i`n compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION . 6 -----y.4WrR--------f CENSUS TRACT <br /> rOwner's Name ----------------------------------:----------- :-' - hone <br /> P <br /> Address /= L !?X S ------- --------------------- City [ E/ Cfl �`'• i�.0 P a <br /> Contractor's Name ---lk�.5-------S,.7;S------------------------------------------------------License # ^------------------ Phone -------------------•--------_ <br /> Installation will serve: Residence Z.Apartment House❑ Commercial'❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> i - <br /> Number of living units.---- ------- Number of bedrooms -� l------Garbage Grinder -NO-__ Lot Size ---��X__�O_-�_-------------- <br /> Water Supply: Public System and name ------------------------ --------------------------------------------------------------------------------------Private c� <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay. ❑ Peat❑ Sandy Loam -❑ Clay Loam [] <br /> Hardpan ❑ Adobe g-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 or seepage pit permitted if public sewer is available within 200 feet,) _A <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= [ ] No. of Lines ------------------- .Length of each line---------------------------- Total Length ._---.-_---------..--.---- N%. <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material _------------------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---------_--- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------- ------------ Rock Filled Yes ❑ No C] <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---------- -------- ----------------------------------------------------- ---------------------------- <br /> i <br /> Disposal Field (Specify Requirements) ------- � 1. ✓r� 1 � <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 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 /> 6 <br /> BY ---------------------- -------------------------------------------------------------------------------- Title ------------------------------------------- ---------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - _- ---- VX'C ---_. DATE --- --- --------------- ------------------- <br /> - ---- -------------------------------------------------------------- -- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE __.---------------------------------------- <br /> ADDITIONALCOMMENTS ------------------ ---------------------------------------------------------------------------------------------------------------=--------------------------- <br /> -------------------------------------- ------------------------------------------------------------------------------------------------------------ --------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------- <br /> - --------- -----------�_f= --- --=------- <br /> Final Inspection b ll�J Yt--------`------------------------------------------- ._.Date __� I <br /> P Y� - �- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />