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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- ------------------ --------------- <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 compliance with County Ordinances No'. 549 and existing RuIq and Regulations: <br /> JOB ADDRESS/LOCA N . °°a - -------CENSUS TRACT ----------------•-------. <br /> Owner's Name -------- - ---------- -- ---- ----`---- - --------- -------------------------- -------------------Phone ------------------------------•---- <br /> Address10,_Xg( -- --- -- -- t --------------- City ----- ---------------------------------- <br /> Contractor's Name -"" ----- ------.License # _� c- -----V__ Phone --------------------------- <br /> Installation will serve. Residence []Apartment House❑ Commercial :❑Trailer Court i,❑ <br /> Motel ❑ Other --_--�'�- , _. <br /> Number of living units:___------_ Number of bedrooms ___-?�7:1._Garbage Grinder ------------ Lot Size --- __ 'ir'- ''_________________ <br /> Water Supply: Public System and name ----------------------•---------------------------------------------------------------------------------------Private [J <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .0 Clay Loam 0" <br /> ""Hard an. ._z : o .r- z - --- - <br /> p ❑ Adobe ❑ Fill Material ------------ <br /> __- 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 see age pit permitted i# ublic sewer is available within 200 feet,) <br /> ,4 <br /> PACKAGE TREATMENT �� I �____ __ __-- Liquid Depth ._ __�___ <br /> [ ] SEPTIC TANK''[ Size ------- <br /> Capacity Type ---_ Material___ __ __ No. Compartments __-__02-------------- <br /> Distance to nearest. Well --------- a__�________ Foundation k-0-0 --------- Prop. Line __-5..0�.----------- <br /> LEACHING LINE [ J� No. of Lines --------r-------------- Length of each line---------- _0_u--.-.-_._ Total Length __ ...... .. <br /> D' Box ------------ Type Filter Material ----6 _4_---.--Depth Filter Material ------ ------------------•-----.-.-- <br /> Distance to nearest; Well -------�+r_-�__ ________ Foundation _____ _---_:_______ Property Line ___ _�_____ <br /> SEEPAGE PIT [ Depth -_.___.p _ -�_ Diameter - ;_~__-_ Number -------/ -- Rock Filled Yes- No .i❑ <br /> Water Table: Depth -----------7e ------------------------------Rock Size - ' <br /> Distance to nearest: Well ----------1_a-4- ------------------Foundation --------- --P_----. Prop. Line .....5'_...___-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ______________--__________________) <br /> Septic Tank (Specify Requirements) ------------ --------------------------------------------------------------------- -------------------•----..__... <br /> Disposal Field (Specify Requirements) ---------------------------•--------------------------------------------------------------------------------------------------------- " <br /> -------------- --------- ------------------------- --------------------------------------------I------------------------------------------------------------- -------------------- ---------- - „ <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`Ruies 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 ensati.on laws of California." <br /> Signed C)i <br /> - --- Owns <br /> BY ----------- s - Title --- t._ ---- -- --_ ---------------------------------- <br /> (lf other than ow <br /> R D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ ---- ----- - - --------- DATE <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------- --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------- <br /> ------------- <br /> ----------------------- - <br /> --------------------------------------------------------- <br /> ------------------------------------------------------------- <br /> ------------------------------------ ----- --------- <br /> -------------------------------------- <br /> Final Inspection by: =G ----------------------------------------------------------------------------------.Date - - --�/- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />