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FOR OFFICE USE: j <br /> / �3o APPLICATION' FOR SANITATION PERMIT ' <br /> ...... ----7a----------- ----- --------- o x- v <br /> � _ Permit No. <br /> (Complete in Triplicate) s <br /> --------------------- --------- <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 permit to construct and install the work herein <br /> described. This application is made in compliance with Co my Ordin nee No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/L CATION .--- --IIs- ---- -------- -- - --- CENSUS TRACT ----------- -- •-------- <br /> Owner's Names--t -------- - Phone <br /> Address ------ ----- Q ------------- Cit -- --------G --=`---------------------------------- ------ <br /> Contractor's Name -. _ __-_ -__---"'_-.._ -__-_-.License # /6J.2:.�_Z-Phone _Vi.J--- <br /> Installation will serve: Residencepartment House,❑ Commercial;❑Trailer Court ❑ <br /> j Motel ❑Other ------------------------------------------ <br /> Number of living units:-----------( Number of V edrooms--__-_-Z-Garbage Grinder/4--L3- Lot Size -�6�� ------------ <br /> y r <br /> Water Supply; Public System and lame _ ---- CL ---------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ &t[] Gay ❑ Peat❑ Sandy Loam ,❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material._'__________ If yes, type ____________________________ <br /> {Plot plan, showing size of lot, location of system in ' elati6n 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 -l------------------ Type ----------- ;---- Material`---------------------- No. Compartments ------ ---------.,. _. <br /> Distance to nearest: Well -----------------'------------__-'-;Foundation ---------------------- Prop. Line ----------------- <br /> LEACHING <br /> --------- :-LEACHING LINE [ ] No, of Lines ------------------------ Length of each fine---------------------------- Total Length _-___-____--._-__----....__ <br /> D' Box _1 <br /> I-------- Type filter Material ---- _`�_Depth'•Filter Material -------------------------------------------- <br /> Distance #o nearest: Well ________________________ Foundation ------------- ---------- Property Line. --------- ------_-_- <br /> SEEPAGE PIT [ ] Depth ___ --------------- Diameter ---------------- `Num"ber ---------------------------- Rock Filled Yes ❑ No ,(3 <br /> Water Table Depth ------------------------------------------------Rock Size ----------------------------- <br /> Distance to nearest: Well _______________________________ i..Foundation _..__.____.____.___- Prop. Line ______--__---_-----_ <br /> € -- 4 -------------1 <br /> REPAERjADDITION(Prev. Sanitation Permit# ________ _______________________ _ __ �-- Date _____-_.___________-_ <br /> Septic Tank (Specify Requirements) -------------------------------------- ---- -------------- ------------------•-- - ------------------------ <br /> Disposal Field (Specify Re uirements) -------------- --- -------i-fi -------_--- ----- ------------- <br /> ------ --- ----------- <br /> { <br /> 1 (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: �•- -i I -° <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 /> Sig `--------------------------------- Owner <br /> BY ---. .1 i Title -- l^P x <br /> - <br /> •(If other than owner) _.. <br /> i R DEPARTMENT USE ONLY ! <br /> APPLICATION ACCEPTED BY -------- el— DATE ------ -------------- <br /> BUILDING PERMIT ISSUED - 1----------------------------------------------------------------------------- -------DATE ---------------------- -------•--- <br /> ADDITIONALCOMMENTS ----------- -------------------------------------------------------------------------------------------------------- --------------------------------------- <br /> ------------------- <br /> -------------------- ---- <br /> y <br /> ----------------------------------------------------------- <br /> b , . - <br /> ---- -- -' ---- '` <br /> Final !ns ection b Dat ------------- -- ------ <br /> e <br /> P Y - --------------------------------------------------------- ----- - <br /> SAN JOAQUIN LOCAL 'H,EALTH DISTRICT <br /> E. H. 9� -. i _68 Rev.-5M `� �.��. . • ' s . :. *� `�> <br />