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OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------`----------------------------- <br /> Permit No.. y-3i e <br /> (Complete in Triplicate) <br /> ---- This Permit Expires 1 Year From Date Issued 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 ismade- in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .--� 7. _� --.- -- G1 ----------------------------------CENSUS TRACT -------------------------. <br /> Owner's Name - - --- - -------------------------------- Phonefca� ��s�ra ------ <br /> Address -- LF-o� .. --------------. City <br /> --------------------------------------•-- <br /> Contractor's Name -- _. ,�- .���- ---------------------------License # Phone _ � <br /> Installation will serve: Residence Apartment House-F-1 Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other ---- ------ <br /> Number of living units..---/------ Number of bedraoms ._.__Garbage Grinder Lot Size ------ Q____r. ..................... 1 <br /> Water Supply: Public System and name . -----------•-----------------------------------------------------------------------------Private [g" <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam E] I <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 /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ) 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 -----l------ Type Filter Material --------------------Depth Filter Material --------------------------------------- <br /> ._.__-- <br /> Distance tonearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ <br /> SEEPAGE`PIT [ ] Depth ........f------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C] <br /> Water Table Depth -- ---------•----------,-- -----------------------Rock Size ------------------------------ <br /> I I - <br /> Distance to;nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -__----_--_---_---_-_- <br /> REPAIR/ADDITION(Prev. Sanitation'Permit# -------------------------------------------- Date _____-_--_----____---_-_----_-_-_-) <br /> Septic Tank (Specify Requirements) _____ ______________________ _____ <br /> -------------- <br /> Disposal Field (Specify Requirements) ---*9- --7- _____, ___ ---.------ � _ _____-_. <br /> ------------- -----------------------------------------------------I---------------------------I------------------------- -------------- ------------------------------ ----,--------- <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 shalt not employ any person in such manner, <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------- Owner <br /> � -------------------------------�--�--- Title -.�-r -------------- ---------------------------- <br /> ------------ <br /> (If <br /> --------- ----------------- <br /> (If other than ner) 'I , <br /> FOR :DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - t""r - DATE --------------�� <br /> ------- -- ---- --------------------- <br /> - ------------- <br /> BUILDING' PERMIT ISSUED ----------------------------------------- -- - - - DATE -Y--- ----------------------- <br /> - - -------- <br /> ADDITIONALCOMMENTS -------------- !------- - -------------------------- ------- ---------- --------------------------- <br /> i -------------------------- - - <br /> ..- --------------- -------/_ n_�V <br /> ------------------------------------------------------------- --------------------- ----------------------------------------- . <br /> - ----------- ----- ---- ---------- -----------Final Inspection by: --------------------------------- -----------------------------Date -----��--� ---_� ------------ <br /> ---------------- <br /> -- ------ f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />