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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> �S�oy <br /> ----=--------------------- <br /> ----- (Complete in Triplicate) Permit No- --------------------- <br /> This Permit Expires 1 Year From bate 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/LOCATION . ---____-- 7__ ._� ' ----s-� -/----------- --- - -- ------CENSUS TRACT ----------:--- ----_- <br /> Owner's Name _. / --- -- � '�' -----------------------------------------------------------Phone------------------------------------- <br /> Address ...7 --- ---------- ------------------------------------------------• City ------------ --------------------------------------------------------------- <br /> r / <br /> Contractor's Name --- -- License # _ �. Phone -- �J.?-1Q <br /> Installation will serve: esidence [> ,partment House i0 Commercial :❑Trailer Court ❑ <br /> Motel ❑Other ------------------------------------- <br /> Number <br /> ----------------- ----------------Number of living units:-------°---- Number of bedrooms -_-- _-----Garbog a Grinder /5._4Lot Size __—------ f+ _5____-------_ <br /> _ � , <br /> Water Supply: Public System and name ------------------------------------ ----=-- --------------------------------------------------Private . <br /> Character of,soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material la---- If yes,type _____________ __ <br /> (Plot pian, showing'-size of. lot, location of-system in relation to wells, buildings, etc. must be,placed on reverse side.) <br /> NEW INSTALLATION:, 1 (No septic tank or seep a pit permitted if public sewer i,s�ilable within 200 feet,) 1 <br /> SSC 10 X S <br /> PACKAGE TREATMENT' [ ] SEPTIC TANK' 4 Size-----------•------------------------------------ Liquid Depth --- -------------,----- 6 <br /> d ��Material_�� _ __ ,No. Compartments --r�___�__._---_.___ Q <br /> Capacity f ---- Type <br /> ,stance to nearest: Well ----ter ---t-Foundation:��--------------- Prop. Line . ----:_-------—0 <br /> IG o° <br /> LEACHING LINE [ No. of Lines __ ___._______ <br /> 1. -Length of each line__ �.________ _____ Total Length ____________________________ <br /> j ------ Type Filter Materia C --_Depth Filter Material -------------------------------- <br /> 'D' Box ---- .r� 4� -/--------- <br /> Distance to nearest: Well _'_I��" ____"__. Foundation ,-._ __.__-- Property Line <br /> SEEPAGE PIT [ } Depth -------------------- Diameter ---------------- Number ___� -.-_------_-----._ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size --------------------------------- <br /> Distance to nearest: Well --___-----------------------------`--j.Foundation .__--.---.------__. Prop. Line -----.----_--_---___--� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------) <br /> Septic Tank (Specify Requirements) -------- ----------------It-EA4-N------�1 ----------------------------:----------------_----------------------- <br /> Disposal Field (Specify Requirements) -- ---- - --36- --_<: Vf- 1�--- <br /> y <br /> _ ------------------_---____________ -------------------------- <br /> 1 + <br /> = _-.--_----_-------------------------------------.------:.__r ::-_--__----------_----_--________-.---------_---------___-_--__ --- __---_-.--------------_-_-___.-------------------- <br /> j" -jDrpwexisting 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 to Workman's Compensation laws of California." <br /> Signed Owner <br /> Owner <br /> BY - -=----- ---------- ' Title <br /> (If other than owned <br /> FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY ---- I --'-R- 0------------------------------------------------------------------------------ DATE �LT <br /> BUILDINGPERMIT ISSUED _---------------- {------------- -------------------------------------------------------- -------DATE - ------------------------------------------ <br /> ADDITIONALCOMMENTS --------------- ---------------------------X --- ----------------------------------------------------------------------------=-------- ------ <br /> ---------------------------- ------------- '---------------- ---- - - -- ----------------------------------------------------------------------------------------- --- ----------- <br />' r ----------- <br /> ----- ------ ----------- <br /> -------------------- <br /> ----- .; -!� C/___ - ------' - - <br /> - - N _-1 <br /> ---------------------------------------Date --------- ---- ---------- <br /> Final Inspection bY <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />