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FOR OFFICE USE: <br /> - ------------------- APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate} Permit No. .,l U _3 ______ <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 /> Cyd <br /> JOB ADDRESS/LOCATI N va----- -- ` 7^ ,D � ' -----•/.`-"'-----CENSUS TRACT --------------- <br /> ry <br /> Owner's Name U's. xMr <br /> Phone . l� = �' <br /> 1, �• <br /> - a T '�f- j ------------------- City -!.__l "---------- <br /> ire <br /> Address ......------- - -- ------�-'�---- ----�-'r"� i <br /> Contractor's Name !l � -------------------------- ---------.License # ---- , ----------------- Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer 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❑ Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- o <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 [ I Size------------------------------------------------ Liquid Depth --------------.----.------ <br /> Capacity ------------------- Type -------------------- Material---------------------- No. Compartments .............. ------- <br /> Distance to nearest: Well ___________________________________Foundation ---------------------- Prop. Line ----...........,.-___. <br /> LEACHING LINE ,j�j No. of Lines _____/_________________ Length of each line------�0--------------- Total Len th ,_ �-_-_-_.__ ._-_.-_ <br /> 'D' Box ------------ Type Filter Material _,C1_' '_______Depth Filter Material ___ --�r___.__ ................... <br /> ....................... <br /> f � i <br /> Distance to nearest: Well _d0---------------- Foundation ___/47--------------- 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 e# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -- ------------------------------------------- -----------------• -----------------------__:- <br /> Disposal Field (Specify Requirements) ____ ------/,I-- ____� �����--'b_______�'I__. <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------- ----------------------------------- --------- ---------------------------------------------- -- -- ------------------------------- <br /> (Draw existingand required addition on reverse side}' <br /> I hereby certify that 1 have prepared this application and that the work will be/one 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: e <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 subject to Workman's Comp n atian law,26falifornic." <br /> Signed ------------- -- - --------------- tiOwner <br /> Si n �`� ----------------------------------- Title --------------------------------------------------------- ------------- <br /> ------------- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- . - --------------------------------------------- ----------- <br /> DATE --/-/ ----�a-J-•----------- <br /> BUILDING PERMIT ISSUED __.______________ _ _DATE ------_--__--._-______________ <br /> - ------------------------------------------------------------------------------------- ------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------- -------------------------------------------------=--------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------- -- - ---- ------ -- <br /> - ------- ---------------- -------------------------------------------- - ------------------- <br /> Final <br /> -Final Inspection by: ---- -----------------------------------------------------------------------Dater 2 ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />