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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. _ - �5-.�- <br /> ----------------------------------- -------------- (Complete in Triplicate) <br /> .d�-2Z <br /> _-� ----------- <br /> -- <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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> f 67 2 /,Z /2-`--------------------CENSUS TRACT — ---------------------- <br /> I 5------------------- <br /> JOS ADDRESS/LOCAT ON .---------- ---------------- ---- c. <br /> Owner's Na c Phone <br /> Address f c` City 3 <br /> ------ ---- <br /> Contrar_tor's Name - -- c ' ---------License # ff ------ Phone <br /> Installation will serve: Residence ❑ Apartment House,❑ Commercial ❑ ❑ <br /> ^Trailer Court ; <br /> Mote! ❑ Other _.__-n ----T ° '`- <br /> Number of living units ---- Number of bedrooms __y---Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> Water Supply: Public System and name ------------------------ ------ ------------------------------------------------- --------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat ❑ Sandy Loam [:1 Clay Loam 1] \ <br /> Hardpan Adobe E] 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 /> S , <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Sizey _s�__----�___---t'____-_---- Liquid Depth --_----------------------- <br /> Capacity -j_ -oG- Typ44.-)__ Material `' ------ No. Compartments ____ .--.-------- <br /> i <br /> Distance to nearest: Well ------:r�.......-------------Foundation ------Z0-....... Prop. Line ------S______-_---- <br /> fI <br /> LEACHING LINE [] . - ------------- Length of each line------------�-�� ---- Total length _-- <br /> 'D' Box ___ '__ Type Filter Material ----4__k------Depth Filter Material --------- ....................... <br /> Distance to nearest: Well --------Se-..______ Foundation /0------------ Property Line -------_________________ <br /> SEEPAGE PIT ) Depth ._____- _� _�_- Diameter -____ _�_ Number _- .______-�___- --__ Rock Filled Yes E No i❑ <br /> Water Table Depth ---------:------��--------------------------Rock Size - ---------X-3--------- <br /> r <br /> Distance to nearest: Well ______-------- 0-o r -.Foundation ------1-L?__r____ Prop. Line ----S------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------•----------------------------- <br /> Disposal Field (Specify Requirements) ------------ ------------------------------------------------------------------- -------------- <br /> ----------------------------- - - <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. Hoene 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 /> By --------------------------------------------------- ----- Title . _ r ----...---------------------------------- <br /> (If other than owner) <br /> FOR DEPARTM NT USE ONLY <br /> APPLICATION ACCEPTED BY --- -- --- ------ DATE �-`---- '- ------------- <br /> - ------- ------------ -- ---------------------------------------- -- <br /> ------- <br /> BUILDING PERMIT ISSUED -------------------------------------- - <br /> ------------------------------------------------------------------DATE ..-- ------•--------------------------- <br /> - <br /> ADDITIONALCOMMENTS -------------------------- ------ --------------------------------------------------------------- ------------- <br /> ------------------- <br /> ------------ <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------'�----------------------------------------------------------------------------------------------- ----------- ---------------------------------- <br /> ------------------------------------- -- ---- <br /> ` -------- <br /> Date <br /> FinalInspection by: -- - - -- - -- - - . ------------------------------------------------------ - - -- ---------- ------------ - ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />