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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. - y' �3-. " <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date issued _ -" � <br /> ------------------------------------------ <br /> ---------------- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> Mh County Ordinance No. 549 and existing Rules and Regulations: <br /> described. This application is made in compliances <br /> JOB ADDRESS/LOCATION .__ -- ----------�--- -�-------------- <br /> CENSUS TRACT -------------------------- <br /> __-_�_--/3F� <br /> Owner's Name -- ---- --- --------' --------- -- ---- --------------- --------------- Phone ----- ------------------•---- . <br /> ----- Cit ----------- <br /> Address " -----------`3---�- 1----------------"- - - --------------- --- --- - Y ----------- <br /> Contractor's Name -.._. <br /> R - --------- -- - -.Licensef 30'_:;?�Phone ------------------------------ <br /> Installation will serve: Residence Apartment House-F] Commercial ❑Trailer Court i0 <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:__ ��__ <br /> .___--r Number of bedrooms __ ______Garbage Grinder ------------ Lot Size ----------_______________ ______ <br /> Water Supply: Public System and name ---------/Acl[cobef-j <br /> -----------------------'t---- - - <br /> Private <br /> Character of soil to a depth of 3 feet: 'kSand t Clay ❑ Pecit❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpan Fill Material-------------- If yes,type ----------- <br /> plan, showing size of lot, location�of system in relation to wells, buildings, etc. must be placed on reverse side.) r�r-• <br /> "-,,NEW INSTALLATION: (No septic tank or seepage pit permitted if-public`sewer-is available within 200 feet,) W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f I Size--------------------------------- � �' =Liquid Depth ___________--------.----- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------........... <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------------- <br /> LEACHING <br /> --------- ---- <br /> LEACHING LINE f ] No. of Lines -- --------------------- Length of each line. --------------------- Total Length ----------------------------- <br /> V <br /> __--____-____.-------- n <br /> 'D' Box ------------ Type Filter Material --------------------De`pth Filter Material -------------------------------------•----•- <br /> Distance to nearest: Well ------------------------ Foundation -----. - ------ Property Line --------•---•-------__-- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- <br /> Rock Filled Yes ❑ No <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 /> -------------------- ------------------------------------------- <br /> Disposal Figld ISpecif Requirements) ___ ___ ___ _________ ___________f `" '- - "_" <br /> --- ---=3--- _ ; <br /> ,+..�,-�-,�- - -- - <br /> e- <br /> �� <br /> - --------- <br /> ----------------------- -------------- <br /> a existing a d required addition on reverse side) <br /> I hereby certify that I have prdared 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 t t in a performance of the worts for which this permit is issued, I shall not employ any person in such manner <br /> as to beco e s ct to Workm 's Compensation laws of California." <br /> Signed �_ . .�. ,- �.. --�- --- ------ caner <br /> - --------- --- -- <br /> ® O <br /> -------- - itle ------------- -----------'---- <br /> BY ------------------------- <br /> (Cf other than owner) `FOR DEPARTMENT USE ONLY <br /> APPLICATION AC PTED BY _____ ---------------------------------------------------------- DATE ° _ -` -'--d_-------------- <br /> BUILDINGPERMIT ISSUED -------------------- -------------------------------------------------------- ----------------------------DATE ------------------------------------------- {. <br /> ADDITIONALCOMMENTS ------------------------------------------- -------------------------------------------------------------------------------------=--------------- ----------- <br /> - ---------------------------------------------------------------------------------------------------------------------------------------- --------------------- ---------------------------- - <br /> -------------------------------------------------------------------- <br /> �------------------- ------------------------------------------- <br /> -------------------------"----- ------ ---------- ------ ------- <br /> ------- <br /> Final Inspection by: ^ Date c '-- <br /> Z <br />► SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />