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.FOR OFFICE USE:k APPLICATION FOR SANITATION PERMIT <br /> ............... .............•----_..:.......- --.- Permit No. S - <br /> (Complete in Triplicate) _ �� <br /> ...._....-•............................................ This Permit Expires 1 Year From bat*Issued <br /> �. 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 applitationpis made in compliance with County Credinance No. 549 and existing Rules and Regulations: <br /> JOB ADPRESS/LOCATION-..- --/• .. .:_ y.. . . ....s..=........: ...... .. ---....._........ .............CE CT........................ <br /> CENSUS TRA <br /> ti <br /> Owner's Name ...- Phone .................... <br /> '�� �C �'-"` --"-...... pity 6 :.. <br /> Address ..... . . _....c , - -- � ---- -- - --••---- - - � � Phone Contractor's Name __ --- ----- ----------- --- f'._.. . _. .!-�!-�----. cense ilk' ../��� .. ............................. <br /> ' Installation will serve: Resid ce[Apartment House] Commercial ❑Traller Court 0 <br /> ti Motel ❑Other <br /> + ............................................ <br /> Number of living units:_..-1------ Number of-bedrooms ._-__Garbage Grinder ............ Lot Size ....•- _....... <br /> WaterSupply: Public System and name . ....... -•-------°. ..............-•---------".._..I.._......... ........ .................•............Private <br /> Q <br /> � <br /> Character of soil to a depth of 3 feet: Sand(=7 Silt❑ i r Clay ❑ Peat❑ Sandy Loam lay Loam ❑ <br /> s Hardpan ❑ Adobe,o Fill Material ..........3: if yes,type ............... ............ <br /> V <br /> i } <br /> (Plot plan, showing size of lot, location'of system'in relation,to wells, buildings, etc. must be placed on reverse sids.l-1§ <br /> NEW INSTALLATION: (No septic tank o seepage pit permitted,if public sewer is available within 200 feet,) <br /> } PACKAGE TREATMENT ( SEPTIC TANK f ] Size--- --'`....................................... Liquid Depth .......................... <br /> Material...................... No. Compartments <br /> 3 s Capacity.` p ...- <br /> Distance to nearest: Well :..........Foundation .. Prop. Line <br /> LEACHING LINE ( 1 No. of Lines ------------------------ Length of eadl line ------ Total Length ............................ <br /> I 'D' Box ............ Type Filter Materia( ; --"-Depth Filter Material --........................................ <br /> Distances to nearest: Well ........................ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT Depth ..- ................ Diameter ................ Number ............................ Rock Filled Yes ❑ No (:3 <br /> Water Fable 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) -•---- --------- - <br /> .>�.. .r., .---- -------•---------- - <br /> 6 I --------------------------------------------- <br /> ........................................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 Son Joaquin Local Health;District. Hoene owner or Ilcon- <br /> sed agents signature certifies the. <br /> 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 subject to Workman's Compensati laws of California." <br /> i <br /> Signed -----------------------------------f�� <br /> . •••. - ---------------- Owner <br /> BY - -- - ----- ----- - ........... Title J? . ------ <br /> (If other than o <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BY r - -----. DATE .,...... •��------ . <br /> -. ... <br /> BUILDINGPERMIT"ISSUED --------{---------•---------------- ----------------------------- ------------------ -- --------------DATE ....- ..----------.........._......--•--- <br /> ADDITIONALCOMMENTS -----------------------••-----•-...--------------------------•-------•---------------..._........-_----._......._..- ------------- ......I--------------- <br /> -------------------------------- ----•- -------•---••----------------------- ---------------------------------------------..-- <br /> ------------------ .................................. -------------------• ---------------------r ....-- ._.------ ...------.._..... _. <br /> FinalInspection by: ----------•--•---- -F... ................................•---"•---•----•-•---•----.._.... ------- •..____..Date ....7 <br /> 9 EH 13 2L 1-68 Rev. 5M ' SAN JOAQUIN LOCAL HEALTH DISTRICT B 7)t 3M <br />