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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT //--(' G <br /> Permit No. 1!/!-=_ !_ <br /> � <br /> {Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued -- .� '- -_ <br /> Application is hereby made to the San Joaquin Local Health District for a per 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/LOC TION .D- Q- -------- -- --- - -------------------------CENSUS TRACT ---S Y-4....-------- <br /> Owner's NaaGme --- -- -- ----- - ---- ------------- ----- ----------- -------Phone ------------------------------------ <br /> Address ---D-----w__---- C --- - ----------------------------------------------- ------- <br /> r <br /> -- -- ---- - - - - - - -- ------- ------- - c _ <br /> Contractor's Name --- --- -- f , - ----- ------- L--- -----.License # 11.3_ _yPhone --------------•----I---------- <br /> Installation will serve: Residen a Apartment House,0 Commercial []Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------- ----------------------------Number of living units:---/______ Number of bedrooms _______Garbage Grinder ----- ------ Lot Size -- ------ - <br /> Water Supply: Public System and name ------------------------------••-------------------------------------- --._...-------- Private [3 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam /CIay__Loam !E] <br /> Hardpan ❑ Adobe'❑ Fill Material ---- ------- If yes, type ---------------------------- <br /> {Plot plan, showing size of lot, location of Sys em in relation to wells, buildings, etc. must be placed on reverse side.) pr, <br /> NEW INSTALLATION: (No septic tank or s age pit permitted ifublic sewer is available within 200 feet,) <br /> r , r S-/ <br /> PACKAGE TREATMENT I I SEPTIC TANK![ Size_'_ _ .----► -__-_------_-_-- Liquid Depth <br /> -- � <br /> ______________ <br /> No. Compartments <br /> Capacity f6 0- Type Materia <br /> r' <br /> ,Distance to nearKt: Well f7t__�--------------Foundation -----!_,c!............ Prop. Line --------- <br /> LEACHING LINE [ No. of Lines -------- Length of each line_____F6----------------- Total Length ---ia;_109.............. <br /> SA, <br /> t� <br /> 'D' Box - <br /> ------- Type Filter Material _t��_[S._�------Depth' Filter Material ___ ?_______--------------/------------- <br /> Distance nearest: Well ___-__a%_f-_--_-- Foundation .___--!_q--�________ Property Line --"' ________________ <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size ------ ------------------------- <br /> Distance to nearest: Well ---------------=-----------------------Foundation -------------------- Prop. Line ---------............ <br /> REPAIR/ADDITION(Prev, Sanitation Permit# ---------------------- ------ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- • -----------------=---------- <br /> Disposal Field (Specify Requirements) ---------------------------•--------------- ------------------------------------------------------------------------•----------- <br /> ti <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 subject man's Co <br /> m sation laws of California." <br /> Signed --------------------- - --- ----- Ow <br /> ner <br /> BY ------ . Title <br /> --- ------------------- <br /> (If <br /> other than owner) <br /> FOR DEPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ - - -'------------------------------------------------- DATE //"-.,c3-7_ _,i�------------------ <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------/-----------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------I-------------------------- --------------------------------------------------=----------•---------------- <br /> --------------- ----------- ---------------------------------------------------------------/------------------------------------------------------------------------------------------------------------ <br /> - --- --- ----------------------- --------- ------- - -------------------- -------1 ----------- ---------- ------------------ - ---------------- ----------------- --------------- <br /> --------------------------------- ----- --------------------- ------------------ ---------- ------------------------------ - I _6----- -------------- <br /> Inspection by: Date <br /> ---- --------- ---------------- <br /> Final SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />