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a ti <br /> FOR OFFICE USE: ` i" <br /> APPLICATION OR SANITATION PERMIT S4 1 <br /> R. _ ' Permit No. _- -- -- <br /> (Complete in Triplicate) <br /> -------- -- ------------ -------------- <br /> ----------- Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> r 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 complian with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------------- - -------------- CENSUS TRACT ---.----------.--•-------- <br /> t one <br /> Name -.A��" ----�$.�•e�i--- --------- <br /> - - --=- - -------------Ph ------------------------------------ <br /> Owner's . <br /> ------------- <br /> ,l ,�� Y <br /> Address 4 -------= c--- Cit <br /> I License # RAS: S Phone -- <br /> Contractor's Name __C� -- -- - ---------- ------ -------- � <br /> Installation will serve: Resi ence Apartment House'❑ Commercial ❑Trailer Court i❑ <br /> k Ik Mote! ❑ Other -------------------------------------------- <br /> Number <br /> ..------- ------------ ---------------Number of living units:...ff.------ Number of bedrooms ------Garbage Grinder�V.._.--- Lot Size /-0 - ----_AP ____________ <br /> Water Supply: Public System and-name ----------------------------- ----------------------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Cl a -E] Peat❑ Sandy Loam ❑ Clay Loam:❑ <br /> j Hardpan ED 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 seep pit permitted if public sewer is ailoble within 200 feet,) <br /> � r- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:;7 -- ------------ Liquid Depth __.</1--------------- " <br /> l No. Compartments --A------------- <br /> -----+ Capacity 0 - Type __.------ Materia6- - _--- P <br /> Distance to nearest: Wel! --- —�-------------------------Foundation --/-------- ------ Prop. Line ,_-4�-_-------------- <br /> LEACHING LINE [W/-No. of Lines ------ Length each line---�P---------------- Total Length <br /> --- ------- f <br /> -_-/ ----------- <br /> D' -_---Depth Filter Material ___r <br /> Distance to nearest: Wel! -_______- Foundation ---------------- Property Line ____ _ ---------- <br /> SEEPAGE PIT [ ] Depth __-_ --_-- Diameter _______________ Number _.__------------------------ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth --------------------------Rock Size -------------------------------- <br /> r Distance to nearest: Well ------------------------------- --------Foundation -------------------- Prop. Line -------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit'# ----------------7--------------------------- Date ----------------------------------} <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------------- -------------------- ------------- <br /> Field (Specify Requirements) ----------------- <br /> r' <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 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, 1 shall not employ any person in such manner <br /> as to bec ubjec to Work an's Compensati law of California." <br /> Signe -- - ----------- - -- --- ----- -------------- - <br /> ----------------. Owner <br /> ------ -------------- -Title ----- ---------------- ---------------- <br /> other than wne <br /> FOR D P M SE ONLY <br /> i <br /> APPLICATION ACCEPTED BY -------------------- ----- -- ------- -- -------- ------------------ --------------- DATE -- - -- ---- - ---- ---- <br /> --- <br /> BUILDING PERMIT ISSUED ------------ -- - DATE <br /> ADDITIONAL COMMENTS - -------=---------------- --=--------------------------- <br /> --------------------�--------------------------- ------------ ----------- <br /> Final Inspection b - {�- <br /> --- -------------- <br /> It------------------------------ ----------------------------------------- -------- Date _---q--__��'l^�_---- <br /> -------------------- <br /> I - ------------------------- - --------- '--- ------- ---- -------------------- ------ <br /> SAN J A LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'68 Rev. 5M <br />