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1wOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ <br /> --- ------ --------- ------ --- -7 _7o <br /> (Complete in Triplicate) Permit No. <br /> --------------------- This Permit Expires 1 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 in((coompliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOC ION -J---��_3__Z_-_, r__-�� C1_►' _P ---------------------------------CENSUS TRACT --- -7----- -.... <br /> Owner's Name ----- - -----------------------•----------------.----------- Phone 3_-6--s_X5...6---. <br /> Address --------:1-D--=I------ -- City --- <br /> ------- <br /> Contractor's Name ---------------------------------------------------------------------------- ----------License # ------- --------------- Phone --------------------..__._.... <br /> Installation will serve: ResidencegApartment House-[] Commercial ❑Trailer Court ;❑ 17 <br /> Motel [7 Other -------------------------------------------- <br /> Number of living units:___________ Number of bedrooms ______Garbage Grinder ------------ Lot Size __- _______ ___ ----------- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam,' <br /> Hardpan ❑ Adobe.10 Fill Material ------------ If yes, type _____"_________-________-__ <br /> Lnt <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) .A <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 [ ] No. of Lines ------------- Length of each line---------------------.------ Total Length -------_____________________ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------I---.----------------------------- <br /> Distance to nearest: Well _"______________________ Foundation ------------------------ Property Line __________________-_-___ <br /> SEEPAGE PIT [ ] Depth ------ --------- -- Diameter ________________ Number ________________"_______ Rock Filled Yes ❑ No <br /> Water Table Depth --------------------------- ------- -------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------.-------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------ ------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------- ---------------------------------------------------------------------------------- <br /> Disposa Field (Specify Requirements) ---------- 4 /(-----r--------------------6----- -- <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 becq e_s bb�ect t"orkman' ompensation laws of California." <br /> Signed �`. --- . ----------------------------------------------- Owner <br /> By ------------ -------------- ---- - ---------------------------------- ----------------- Title ---------""----------- - <br /> --------------- - --------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 13Y / -------- ---- - --- -- ----- ----------------------------------------------- <br /> -- -- --- ------------. DAT ---- ---- - = <br /> BUILDING PERMIT ISSUED ---------------------------------- ------------------------------------ ----DAT <br /> ADDITIONALCOMMENTS ---"--------------------------------- -------------------------- ------------------------------------------------------------------- ------------ -- ----------- <br /> ------------------------------------- <br /> ---------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------- ----- <br /> ---------------------------------- --- �f - <br /> - ---------- ------ <br /> Final Inspection by: ------------ ---- - ---- -- __111C--- ------- Date --------- k <br /> - --------- <br /> SAN QOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />