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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: -_-__.__'.___-__ _ <br /> ----------------------------------------------- <br /> Date Issued <br /> --------------- ----------------------------------------- This Permit Expires 1 Year From 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 /> _ <br /> JOB ADDRESS/LOCArnTION .--- �-)2W �O-A-_O_�'_________ I�_�----------�� _CENSUS TRACT __________________________ <br /> Owner's Name _�KXA1_s T__.F-,CkR0�1�A---- ------------------------------------------------------Phone ----------------------------------- <br /> Address '�� �wT. CP+ --1+1 /!/G City ��� T--------- ------------ <br /> Contractor's Name ---------4r_6....1`fd �--— # Phone <br /> Installation will serve: Residence Wirpartment House,❑ Commercial ❑Trailer Court 11 <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units:-----/----- Number of bedrooms ___1__-__Garbage Grinder ------------ Lot Size ______________ <br /> Water Supply: Public System and name ------------(5t,N4.X- 9'---------------------------------------------- ------------------------.------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay eat❑ 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 /> N <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size___ ----XAZ-_._____--____ Liquid Depth ----4!:�0•------------- <br /> Capacity /'10" ----- Type ____________________ Material -----M57 Compartments .....*2............. <br /> Distance to nearest: Well ------------------------------------ ------------- Prop. line ---------I:---------- <br /> LEACHING LINE [ ] No. of Lines --__-_e0-____-_____ Length of each ��line---_--_416—-_-______ Total Length ---- ................. <br /> 'D' Box ----- Type Filter Material f l_o _Depth Filter Material ----1_ ------ .......................... <br /> Distance to nearest: Well _______________________ Foundation ---/W_/---------- Property Line ----- ................ <br /> SEEPAGE PIT Ey 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 ----------------------------------) I <br /> Septic Tank (Specify Requirements) ------------------ ------------------------------------------- ----------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) _.-._-__---. <br /> --------------------------------------------------------------------------_______________________________________________ <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 become subjeV t9oWorkman's Co ensation laws of California." <br /> Signed ------------------ ---�-------- -- ----------------------------------------------- Owner <br /> BY --------------- -------------------------------------------------------------------------- Title ------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ---------------------------------------------------------------------------------------------. DATE _.-------------- ------ ------------------- <br /> BUILDINGPERMIT ISSUED --- -------------------------------------------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------------------------------_--- <br /> ------------------------------------------------------- ---------------------- ----------------------------------------------------------------------------------------------------------------------- <br /> ---- --- <br /> --------------------------- ---------------------------------------------------------------------------------E - - --}-- ----------------------------- -A--- s------------------------- <br /> Final Inspection by: ---------- --- - - --- ---------------Date -----0_,t.)------------ <br /> SAN JOAQUIN LOCAL H H DISTRICT <br /> E. H. 9 1-'68 Rev. 5M C g <br />