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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------ --------------------------- (C) (Complete in Triplicate) <br /> Permit No. __7A_�A.>7L- <br /> -- - <br /> ----------------------------------- <br /> !7 <br /> --------------------------------------------------------- <br /> -_______--------------_-_.-_-_.__-_____.___-_--__-- This Permit Expires 1 Year From Date Issued <br /> Date Issued --/:1."_rev <br /> *X <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 Ordinanc No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION :_sett '`za-c�_ ,q — ____-. ___________.._ CENSUS TRACT _.-----------_---------- <br /> Owner's Name .__. � 11 ---------------------------------- -------Phone <br /> Address ------ 1403-- 5--------4-77-� City .' <br /> _ -------------------------------------------- <br /> Contractor's Name --- �----------------------------------------License #eV_ _'0 ti' Phone ---------------------_------ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑railer Court ;❑ <br /> Motel ❑Other ------------- ------------ •--------- <br /> Number of living units:_______ Number of bedrooms _.-------Garbage Grinder _________ Lot Size _ _ ............. <br /> Water Supply: Public System and name ----------- ------------------ ---- ------- ----- -- -------•-------------------•---------•------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt[] Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <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.) <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 ---------__................. <br /> 'D' Box ------------ Type Filter Material ----------------_...Depth Filter Material -------------------- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line -------------------_-- <br /> SEEPAGE <br /> _______•_______--- __-.SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No c] <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well -__------------------_--_---_____-__--Foundation -------------------- Prop. Line ...................... ( ' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------_----------------------------------- Date ----------------------------------) W <br /> Septic Tank (Specify Requirements) -------------------•- r ---------:---------------------•----•----------------•-------------------------------_..--•-------•-... <br /> "Disposal Field (Specify Requirements) ------el---X_.5---- ),-";pa---1----------------------------------- ------------------------- <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 /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to o an's o pensation laws of California." <br /> Signed- -�------ - --- ------------------------------ --- Owner <br /> BY ---------------------------------------------------------------------------------------------------- Title ----------------------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT US ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------- - �- ---- ----------------- ------ DATE ----�C� �_ ------------------ <br /> BUILDING PERMIT ISSUED f`' ---DATE -------------------- <br /> -------------------------------------- ---- --------- ---------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------`-✓--------------------- ---------------------------------------- ----- --- ------------------ <br /> --------------------------------------------------------------------------------------------------------••----------------------- ---------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------- ---------- -------------------------------------------------------------- <br /> Final Inspection b --•-- -- 0 Z <br /> - <br /> P Y ------ ------- ---- - -------- - - ---- - Date . <br /> SAN JOAQUIN LOCAL HEAL (STRICT <br /> E. H. 9 1-'68 Rev. 5M <br />