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• FOR-OFFICE USE: ` <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------ <br /> - -------------------------- (Complete in Triplicate) Permit <br /> �- R Date Issued _4//7-2_ <br /> -------------------------------- --------_---------------- This Permit Expires 1 Year From 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> J08 ADDRESS/LOCATIONn-------------------_----CENSUS TRACT ---y------------_ ....... <br /> Owner's Name ---- 11-7 ---------------------- Phone �___!�___ 3_ � <br /> Address /S0 ----- `5------ <br /> ------------------------------------------------- City 71/- bp-----------------------------•--•--•-------- <br /> Contractor's Name -- ------------------------------------------ # _ Phone - r3CC <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court F] <br /> I <br /> Motel ❑Other -- -------------------------------------- <br /> Number of living units:.-/----- Number of bedrooms :2--_..._Garbage Grinder ------------ Lot Sizefzf�____ _ �__._____ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam lay Loam ❑ <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 [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity <br /> ----------------- - -_.-- <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 ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------.--._.---- <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ------------------------ <br /> SEEPAGE <br /> ______-__----___-----_SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ----------- ---------------- Rock Filled Yes ❑ No C <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ___.___--_--_-----__._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit s# _______.------____�.__�__^___-/____________ Date __________________________________) <br /> Septic Tank (Specify Requirements) ----/0 C�rad�------Il�f��"-------------------------- .-------=-------------------------------------------------------- <br /> Disposal Field (Specify Requirements) -oma- fG�------ — / __ 11. ------------------------------------------------------ <br /> ----------- o ------------------------------------------------------ <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 to ork n's Com ensation laws of California." <br /> Signed --- ---- ------- -- ----- ---------------------------------- Owner <br /> By ------------------------------------------------- - -------------------------------------------------- Title ---- ----------------------------------- <br /> ------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = ---DATE <br /> BUILDINGPERMIT ISSUED --------- ----------------=-=-------------- --------------------------------------------------------------DATE - ----------- ----------------------------- <br /> ADDITIONAL COMMENTS <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --- ------------------------------ --------------------------------------------------------------------------------------------------------------------- ---------------------------------------- - <br /> -- <br /> LP <br /> Final Inspection by: ---------- ---- ---------------------------------------------------------------Date --- ------�--_�Jz'--------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1_'58 Rev. 5M <br />