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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> - <br /> ------------------------=------------------------------ <br /> {Complete in Triplicate <br /> -----------­ --------------------------------------- Date lssued/,-----fid. <br /> This Permit Expires 1 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 /> JOB.ADDRESS/LOCATI -14-717 <br /> - <br /> CENSUS TRACT _S <br /> --- <br /> Owner's Name ------- � `��'- -'-- -- --- ----- --------------- -------------- <br /> -----Phone ------------------------------•- <br /> Address _:._ `' <br /> C. �r'�, - _J City ��� e~�------------------- ------•-------------- <br /> . <br /> License # )40 y Phone ------------------------------ <br /> ,tontractor`"s Name _______ --------- ----- ------- -- <br /> 'Installation will serve: Residence Apartment House,[] Commercial ❑Trailer Court ',❑ <br /> k'. <br /> Motel ❑Other <br /> __ ___ <br /> Number of living units:----- <br /> )---'Number of bedrooms ---__.__Garbage Grinder ------------ Lot Size _______ _ ________ ______ <br />� �-... Water Supply: Public System and name ---------------------------------------------------------=--------------------------------------------------- <br /> .Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.0 <br />' Hardpan Adobe-❑ Fill Material -------- --- If yes,type ---------------------------- <br /> (Pilot Ian showingsize of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) <br /> (Pa p <br /> E p age pit permitted if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: (No septic tank or seep <br /> PACKAGE TREATMENT [ ] [ ---__ Liquid Depth ---V---------------.--.-- <br /> SEPTIC TANK' Size-�#1__X-- ----�---'S---------- <br /> aZ G a e - _-_- Material_- ----- No. Compartments -s�..- .------ <br /> CapacitY -- TYP <br /> Distance to nearest: Well -------- p-----------------------Foundation -0-------------- Prop. Line AC-� V <br /> ---_-------- <br /> LEACHING LINE No. of Lines --- ----------- Length of each line____ ------ Total Length ,_�a_�.____._.___•-••-- <br /> D' Box ___Y-____ Type Filter Material ---.---Depth Filter Material -------/-g -------------------- <br /> Distance to nearest: Well -----—$'Q-/--------- Foundation ------- _A'__---__-__ Property Line_ _$:------------------ <br /> i SEEPAGE PIT [ Depth - 2l_______ DiameterNumber ________- ___ .__--�'_ Roek Filled Yes '[�No 0 <br /> Water Table Depth ---------------- Q----------------= ----Rock Size <br /> Distance to nearest: Well ------------- - ----------------Foundation -- -U,10-_____-- Prop. Line ---. -------•------- <br /> % <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---------------------------------- Date _-_-___________-------_-----------) <br /> Septic Tank (Specify Requirements) -------------------- ------------- ' <br /> Disposal Field (Specify Requirements) ---•------- <br /> ----- --------------------------------------------------------------- -=----------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) r <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 toWorkman's Compensation laws of California." <br /> Signed " /:- ;7---- - -- ---- -- <br /> ----------------- Owner <br /> Titlee�' <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ - -- --- ---- --------------- ------•--- ------------ - <br /> ----------------- DATE - F ------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------- ---------------L--------- <br /> -------------------------- - -- ------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------- ------- ----- <br /> - -------------------------------- <br /> ------------------------------------------------ -------------------- <br /> ----- - ----- - -- - -- -------------------------------------------------------------------------------------------------=------------------ <br /> -------------------------------- -- ------- <br /> Final Inspection by: ------ --------Date/Q-_���-�------ ----- ---- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E, H. 9 1-'68 Rev. 5M. .-- , <br />