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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ra=cr! -- --- Permit No -- <br /> . - -------------- - <br /> tiy <br /> y-3 O f^, (Complete in Triplicate) <br /> - -------------------------------------------- <br /> ------------ -------------------------------------------------- This Permit Expires I Year From Dote Issued <br /> 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 /> .JOS ADDRESS/LOCATION .-.��-�`�_ <br /> ---- -------------- - ------------------------------------------------------CENSUS TRACT -------------- ----------- <br /> Owner's <br /> --- ---------•----------- <br /> Owner's Name -`7��aZ `x_wLe}: !----0 "_I�--•------------------------- Phone -oil <br /> Address - ------------ City - ---------------- •------ <br /> Contractor's Name ---- Q'1 _--.License #fir t0_ Phone <br /> Installation will serve: Residence Apartment House❑ Commercial {]Trailer Court ;❑ <br /> Motel ❑Other <br /> -------------------------------------------- <br /> Number of livingunits:-- Number of bedrooms ---- ----Garbage Grinder .-- `---.- Lot Size _1/d_ _____ <br /> �1--_�J��'�__r <br /> ------ <br /> Water Supply: Public System and Aame ---------------------------------•-----------------------------------------------------------------------------Private } <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat 0 Sandy Loam-E] Clay Loam [] <br /> Hardpan ❑ Adobe PQ Fill Material ------------ If yes,type ---------------------------- <br /> r <br /> (Plat 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,) UT <br /> r <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size---------------------------------------- ---- Liquid Depth --------------------,----- <br /> Capacity ------------------ Type -------------------- Material---------------------- No. Compartments ------•-- ............ 0 <br /> Distance Jp nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------_------_----.--- <br /> LEACHING LINE JX No. of Lines <br /> ------J✓--------------- Length of each line------,,J,1-(J---.------ Total Length z�---------------- <br /> D' $ox --1-_____._ Type Filter Material ------- ---------Depth Filter Material ---_--//_< ---------------_-_---_-----_._ - <br /> Distance to nearest. Well ----------------_- Foundation s------ Property Line _ ------------- <br /> SEEPAGE PCf" Depth ---- ----- Diameter _ '111Number ---------l-----____------- Rock Filled Yes ) No i[] <br /> Water Table Depth ----------------------------Rock Size ------;:X----------------.. <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------.----. t <br /> r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -----------_-----------_--__---_--) <br /> Septic Tank (Specify Requirements) ------------------------ _A1,:51........ <br /> DisposalField (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------•--------------- ` <br /> I <br /> ---------------------------------------------------- - ---------------------------------------------------------------------------------------------------------------------- ---------- ------------- <br /> --------- --- ---------------------------------------------------- ---------------------------w - ------------------------------------------------- <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 /> t <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 to Workman's Compensation laws of California." <br /> Signed ---------------------- -- -- Owner <br /> By ------ -- -- _ Title Com- ---- ---- ---------- <br /> --- ---- <br /> (If other than owner) <br /> OR,--D MENT USE ONLY <br /> APPLICATION ACCEPTED BY - Y DATE •Z � <br /> BUILDING PERMIT ISSUED ......... -- - -- - - --- ----- ----------------------------------- --------------DATE -------------------------- ------ <br /> ADDITIONALCOMMENTS Y rr = --------- - - ---- -- --- --------------------------------------------------------------------------------------- <br /> } <br /> ,� ; <br /> -- - ---------------------------------------------------------------- <br /> ------------------ ----- -------- <br /> =------------------------------------- <br /> ---- --------- - <br /> Final Inspection by: -- --. <br /> - Date -���r <br /> 1I � N tJ QUIN LOCAL HEALTH DISTRICT <br /> V�. <br /> E. H. 9 1-'68 Ee . 5M <br />