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FOR OFFICE USE: A <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No., <br /> (Complete in Triplicate) <br /> ----------I-------I--------------------------------------- <br /> This Permit Expires I Year From Date Issued Date Issued 1V7 y. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein a <br /> .describ - This application is made in com lianc with Cpunt Ordinaryc a No. 549 agnc�existing Rules and Regulations: <br /> e�tk! eeV �pN-Q. <br /> pp -�!Z e e t'�/1+1� 2eN�Ji C�y�i+vJ k�d <br /> r <br /> JOB ADDRESS/LOCATION ------X9(2/? f------_ -- /n-1---- ---- ,s�----a --C°�tZnl --=---CENSUS TRACT -------------------------- <br /> Owner's Name /e)1--- Y�awv.l1,7� --------------------------- - ---� Phone -- -2 <br /> Address -Ci91w - ---------------- City - ''--------------------------------------•-••---- <br /> Contractor's Name ----------------------------License # ` _ Phone -' - <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑Trailer Court <br /> Motel ❑ Other -------:5_X8- - --------------- <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder --------- -- Lot Size1 _--___-.________ <br /> Water Supply: Public System and name --------------------------• ------------------ -------------------------------------------------------Private DF �. <br /> Character of soil to a depth of 3 feet. Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <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 or seepage pit permitted if public sewer is available within 200 feet,) � <br /> I <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size__ _ __ `-a--._ _ Liquid Depth __ _____,_____ ' <br /> Capacity _ ____.,__ Type ___ _ MI aterialo. Compartments _ :_ ______..__ <br /> Distance to nearest: Well --------_0- ___ ___________Foundation __�_e-------___ Prop. Line _vim_____---:_.______ <br /> LEACHING LINE [ ] No. of Lines ----f----------------- Length off, eachne--- - -------------- Total Length - --------------.. <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 i❑ <br /> if <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> I� <br /> Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ...................... <br /> 'F <br /> REPAIR/ADDITION(Prev. Sanitation#ermit# ____________________________________________ Date ---------------------------------- <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------:-----------------.----------------------------- { <br /> Dispos I Field (Specify Requirements --------------------f-------,----------------------------- -�------------------------- ---------- <br /> - ----- <br /> ------------ '-- ---------- ------------------------ <br /> ---------------------- ----------------;---------------------- ----------------------------------- ------------------------------------------------------------------------- <br /> (Draw existing <br /> 1H <br /> I <br /> 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, aria Rules and Regulations of the Sar► 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 /> s to become subject to Wor <br /> g an's(Compensation laws of California." /� t <br /> Sined �-------------- --- - -------------------------- Owner 7� <br /> (J' <br /> By ----------4-: <br /> -------- ----------------------- Title --------- ------ ------------------------------- ----------- <br /> (If other than owner)' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY I ----------------------------------- -- DATE __/p 2s �-----------. <br /> BUILDING PERMIT ISSUED ------------ I----------------------------------------------- --------- ----=--------------DATE -- <br /> ADDITIONALCOMMENTS -------------- ------ -----------------------------------------------------------------------------------------------------------------•--------------------- <br /> ------- ----- --------------------------- --------------------------------------- ---------------------------------------- <br /> --------------- ----------------------------------- -` -------------- -------------------------------------------------------------------------------------- <br /> -------------------------------------------------- <br /> - ------- - ---------------- <br /> ---------------------------------------------- - <br /> Final Inspection b -� � - <br /> Py: ------------------- ------ Date --- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> e <br /> E. H. 9 1-'68 Rev. 5M <br />