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FOR OFFICE USE: ` ' +0 P <br /> APPLICATION FOR SANITATION PERMIT �� �� <br /> - Permit No. . <br /> (Complete in Triplicate) <br /> - ------------------------------- ------------- <br /> ---------------- ------------- ------------------------- <br /> ------------___,__.________..______.__.____________________ f� This Permit Expires 1 Year From Date Issued <br /> Date Issued-1-1_7L.. <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 7 --__ ✓�_f�. �>__ CENSUS TRACT <br /> Owner's Name tP -tis 3IV1fZ - Phone _, 5 `� a c � <br /> ---------------------------- - ----- - <br /> Address ----�7 L' t t^t ?�; 5�A�------9--I>----------- - ------_-. City - /, -------------------- -------- --- <br /> Contractor's Name -- eft-e"` , s a -- --.License # Phone <br /> Installation will serve: Residence House,❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------------------------ <br /> Number-of living units:----/------ Number of bedrooms _________Garbage Grinder ------------ Lot Size __� l.____.E ,r_ ........... <br /> !17 . _ 4 <br /> Water Supply: Public System and name .______ � ._ f__._____ -4_____.___________________________________________Private E] 'v► <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt F] Clay Sandy Loam ❑ Clay Loam ;❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If Yes,type ---------------------------- <br /> 0 <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 f ] 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 <br /> -_---___-_.Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --------- .............. <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes 'j] No C] <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ____--_-__----------___-__-_______) <br /> Septic Tank (Specify Requirements) --------------------------------------------------------- - - --------------- -- - -- --- <br /> Disposal Field (Specify Requirements) --------- ,_ ._�Z_------44-'Ove---- -__-__Z'/__-!___--p ___wL C................. <br /> ---------/ ----- D57/------------A`J'_--'---k4ty-6--------------------------------------------- ----------------------------------------------------------------•- <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, 1 shall not employ any person in such manner <br /> as to becomeiject to Work--man's Compensation laws of California." <br /> Signed - ------ ;,� tZ------------------------------------ Owner <br /> BY --- --------------------------------------------------------------------------------------------------- Title ----------------------------------------------- ----------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY --------------------------------------------------------------------------------------------------- DATE -.-.--------------------------------------- <br /> BUILDINGPERMIT ISSUED ----- ----------------------------------------------------------------------------------------------------DATE -------- --------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------=------ ------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - -- - ----- -- --- --- ------- ----------------------=------- <br /> FinalInspection by: ------------------------ ------------------------------------------ ----------------- Date ------- <br /> SAN JOAQUIN LOCAL HEALTH STRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />