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i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------- ---=------- <br /> - (Complete in Triplicate) ` <br /> Permit No 12 <br /> ------=---------------------- <br /> Date issued <br /> _ This Permit Expires 1�-.year From Date Issue <br /> Application is hereby made to the Son Joaquin Local Health District fora 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 /> CENSUS TRACT ------------- <br /> JOB - <br /> --------- <br /> ADDRESS/LOCATION ------ Phone <br /> F ---------------•--- <br /> Owner's Name --------------------•---•------------------- <br /> ```` 1 City ' ' <br /> Address -----/1-- L Phone -------------- <br /> F - r <br /> �`: ] icense --- <br /> Contractor's Name <br /> Installation will serve: <br /> Residence, Apartment House Commercial Trailer Court <br /> Motel ❑Other -------- ----•------- <br /> i Number of living units ----- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ___ <br /> Private <br /> y <br /> ------------------------------------------------- <br /> Water Supply: Public System and name <br /> pp Y= Y - <br /> i Silt Gay .❑ Peat❑ Sandy Loam Clay-Loam'❑ <br /> Character of soil to a depth.of 3,feet-. —.Sand-Sand ❑ ; <br /> t t <br /> Hardpan ❑ (Adobe ❑ Fill Material ------------ If yes,type --------------•--------- } <br /> reverse side.) <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on I ± <br /> ten <br /> NEW INSTALLATION: (No septic tan�br's'eepage pit permitted if public sewer is available within 200 feet,] <br /> _t Liquid Depth .-- •--------•--- <br /> C <br /> PACKAGE TREATMENT [ I SEPTIC TANK [ ]1 Size--------------------------------------- <br /> q De p, <br /> Compartments ---- - • ------•o� <br /> Capacity - Type -------------------- Material-------" • <br /> I Distance to nearest: Well _______ _ ____ --------------Foundations--------- -------- Prop. Line________-- .----•-•--- <br /> a f #---- Total Length <br /> 1 LEACHING LINE 1[ ] No. o' Lines ------------------------ Length of each line------ <br /> 1 <br /> 'D' Box ------------ Type Filter Material" ----- DePth�Filter�Materia ------,---------==--I <br /> -- -.._ <br /> ( I_'_- __-' dl=oundafiion Property Line ----------•-------------- <br /> Distance to nearest: We <br /> H <br /> --�------- ------------Number -------------=-��--�-- Rock'Filled Yes ❑ No � <br /> j Depth Diameter _-4•�------�' <br /> SEEPAGE PIT [ ] - - <br /> i ° --Rack Size ---------------- ------ - <br /> { Water Table Depth r ; <br /> ' t Prop. Line..--------------------- <br /> Well ___ ------- ------- <br /> Date_ <br /> Foundation, <br /> Distance to nearest: -------- <br /> - <br /> bate _.�,-'-�--�-------=-------- <br /> REPAIR/ADDITION(Prev. SanitatiAn^Pemit# _e-------------------------------------- <br /> ----.---] <br /> - ~ <br /> I _ ---------- ---------- <br /> Septic Tank (Specify Requirements) ------------ ------------------- <br /> Disposal Field (Specif <br /> Re <br /> quiremets) ` ---------------------------------------------- <br /> -------�- <br /> = ----- ---- <br /> ------------ <br /> o4 4ac----- ---- ' M, - ------------------------ <br /> /./� <br /> --- � <br /> -------- <br /> '�"'t <br /> w.ersting and required a dition on reverse sidel <br /> I hereby e;tify`that I have pre ared 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 become suFbjec t orkman's Compensation laws of California." <br /> y <br /> Signe ----- Owner, <br /> ------------ <br /> BY -------- <br /> --- ---- ------------ - <br /> - ----------- Title - -------- ------ --------- . ---------- <br /> F + (1f o r than owner) <br /> i ;117=1 Of--'-FOVDEPARTMENT"USE"ONLY <br /> APPLICATION ACCEPTED BY !V DATE .. Y 7 - <br /> 3r z ► DATE ----- ------ <br /> BUILDING PERMIT ISSUED _-----=------------------------------ <br /> ADDITIONAL COMMENTS --- ------------------------------------------------- --------- <br /> ----------------------------- <br /> ---------------------=-------- -;----------------------- ------- <br /> ----------------------- -- - <br /> - - - - - -- - -- -------------- <br /> - -- ------ <br /> ---------------------------------------- - p <br /> Datel - �- <br /> ------------ ------------------------------------------------------------ - <br /> Final Inspection by: ------------------ ------------------------ <br /> --- ---- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />