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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> r------------•4:-------------------- <br /> 9 <br /> -------------------- <br /> (Complete in Triplicate) Permit No. ----- <br /> This Permit Expires 1 Year From Date Issued <br /> --------------------------------------------------------- <br /> Date Issued ---T-3.0-n-7- 1 <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/LOCATION .L_t1.8- ---- __ ).kw--_YSFv4rCG - ---- _&CENSUS TRACT __.�.5________________ <br /> Owner's Name1pe—--------------------- -------Phone --------------------- <br /> ��,, /�,, <br /> Address ----------- onM f_lt:+w __R ------------------------------------------- City --- 12�l <br /> Contractor's Name ------------------- ""-'----------------------------------------------License # ---------;-------- ----- Phone -------•--------•-- <br /> ---------- <br /> Installation will serve: Residence Uf4partment House❑ Commercial❑Trailer Court ❑ <br /> Motel ❑Other --------/------------------------------------ <br /> Number of living units:_.____--- Number of bedrooms ....!___-_-Garbage Grinder ----- '.__ Lot Size......b„ X--________________________ <br /> Water Supply: Public System and name --------MOW- -------------------=-----Private ❑ � <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam ;❑ <br /> Hardpan ❑ Adobe kEr'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 ---------------------- O <br /> Distance to nearest: Well ______________________-_________.._Foundation ---------------------- Prop. Line.-_,-____.............. <br /> LEACHING LINE [ ) No. of Lines -__-_-- ------------- Length of each line---------------------------- Total Length ---_......_................. <br /> �D' Bok''------------ Type Filter Material ....................Depth Filter Material -------------------- .... c <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line --___-_-_.-_-___------__ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> n / <br /> Septic Tank (Specify Requirements) ----------Ak6 lm---01------��---i-----1 eqe '1--- kaur—a.----------•--------------------------------•------ <br /> DisposalField (Specify Requirements) ----------------------------------------------------------- ------------------------------------------------ ------_--------------- <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 /> "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 becpm Iect o Workman's compensation laws of California.” <br /> /J <br /> Signed ---! of x Owner <br /> By ------------------------------------------------------------------------------ ------------------------ Title ------------------- -------------------------------------------------- <br /> (if other than owner) <br /> FOR DEP TO LY <br /> APPLICATION ACCEPTED BY __._____--__________________ ____________--_ .-- ___ <br /> -----=--- -- - - - -----. DATE --------�n- ----f----------------- <br /> BUILDINGPERMIT ISSUED ----- ------------------- ---- ---- -- ----------------------- -- ----- -----------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ----------------------------- --------------- -------------_-------------- ------------------------------------=----------------------- <br /> ---- ------------------------------------------- ---------------------------------------------------------------- p - - --Q-� t <br /> Final Inspection by: ------------------------ -------------- --- ate ------1----------------------- <br /> q�:Ql <br /> i�4 <br /> JOAQUIN LOCAL HEALTH D1_ RICT <br /> Com` <br /> E. H. 9 1-'68 Rev. 5M <br />