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FOR OFFICE USE: <br /> --------------------------------------------------------- APPLICATION FOR SANITATION PERMITPermit q <br /> --------------------------------------------------------- - 0 (Complete in Triplicate) <br /> No: <br /> Date Issued <br /> _________________________________________________________ Tis Permit Expires 1 Year From Date Issue <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. X49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION (_ ___.___a J_-______ ----------------CENSUS TRACT ____-___-__�---------.- <br /> Owner's Name e6------t�d6G�------------------------------------- --------------------------------- <br /> -------------------Phone <br /> Address ------------Oaole1-___ rcc S � •c <br /> Contractor's Name -- /�P--. ------------------------------------License # --- --------- Phone ----------------------- ------ <br /> Installation will serve: Residence House❑ Commercial ❑Trailer Court <br /> Motel ❑Other --------------------------- ---------------- > <br /> loe <br /> Number of living units:--------____ Number of bedrooms ._------Garbage Grinder ------------ Lot Size A41 -----___--_--__-__ <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 ❑ Clay Loam;B <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________--_---_____ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size_____________________________________________ Liquid Depth _--_-_-_-___---_--_______ <br /> Capacity -------------------- Type -------------------- Material--------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well -_-______________________________Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------_--_-_ 0 <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 /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation --_--__----_- ------ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------- --------------------- ----------------------------------------------- <br /> Disposal Field (Specify Requirements) ______ IT . --______-44-, ✓�.�--___ 1 ____ dr/._______ ---------- <br /> ------------------------------------------------------------------------------------------ <br /> --------------------- --------------------------- - ------ -- -------------------------------------------- ----------------------------------------- <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 Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 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 ---- ----- - - ---v/� J S-------------------------------------------- Owner <br /> By ------ ------ ----------------------------------------- Title ----------------------------------------- --- ----------------------- <br /> (If o er than owner) <br /> FOR DEPARTMENT USE LY <br /> APPLICATION'- ACCEPTED BY <br /> ----------- ---------- - - °---- - ---- �--. DATE -------1----- -7----------------------- <br /> BUILDING PERMIT ISSUED ------------------------------------ --------- ------------- -------- ----- ----- -- --------------- DATE <br /> ADDITIONAL COMMENTS -------------------------------------------- ------------ ------------- - <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - - - --------------- -------- - - --------- ----------------------------------------------------------------- <br /> - - - - - - - - - - <br /> Final Inspection b ----------------------------------- ----------------- - ----t Date . - 2!-------------------- <br /> SAN JOAQUIN LOCAL HEALT (STRICT <br /> E. H. 9 1-'68 Rev. 5M <br />