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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> . / <br /> --- - - Permit No. <br /> (Complete in Triplicate) �"�"l`""' <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 /> des �ri9bed�. Th' ap licati n is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ,, / 4v S 0 cruet £ S - z .. <br /> JOB ADDRESS/LOC T N.J-- ----- .L .._ . .. .. / ` ...... _ CENSUS TRACT .... <br /> Owner's Name ......... -//-- •. ------ --- • p--------------------_- ---------- -------- ----.Phone <br /> Address _ _ <br /> . ... - <br /> � �-.:�...1.. .--------- -- - <br /> ------------------ ------------ City - ----------------------------------..---- <br /> Contractor's Name . - � -. « 16V. �&..' <br /> ---- -- -- --- - ---- ---- ---License # ���.- - Phone ...-...-------•- -- --- - <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial�<Trailer Court ;❑ <br /> Motel ❑Other ------------------------------- .......... <br /> Number of living units:---- ------- Number of bedrooms _-_--._-".Garbage Grinder .._-._.- . Lot Size ..-.............-..____..------.._..___- <br /> Water Supply: Public System and name ----------- ----------- ----------------- ------------- ---. ....... ---------- .............................Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay 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 /> ..__----------_---_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 ...----------I.............................. <br /> Distance to nearest: Well ------------------------ Foundation . ................... -- Property Line <br /> SEEPAGE PIT Depth -_. _.. .......... Diameter ---------------- Number ---- ----- . Rock Filled Yes ❑ No ❑ <br /> Water Table Depth -------------------------------- ---------------Rock Size ... . -- ----- . ---...------.- <br /> Distance to nearest: Well ----------------------------------------Foundation ..-.-..-..-------.-. Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------_-..-..-_.-_............... Date -----.--------.-------------------) <br /> SepticTank (Specify Requirements) _.-.....--- -_--------- ----------------- ---------------------------------------------- -------- ......-- ---------------------- <br /> Disposal Field (Specify Requirements) - ---- -- --------- --------- -r----- -- -- - ` ----------------- <br /> 0 LI-1 <br /> 6 <br /> ----------------- ----------- . ------ .......... ---------...............-- ........... <br /> . . . . .._....... `/-------..- -- ------ -------------------------------------------------------------------------------- ---------------------- <br /> (Draw existing and r quired 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 Workman's Compensation laws of California." <br /> Signed - ..... . ------ -. ............ -- ------------- ------------. Owner <br /> By .._. - Title --------------- . ------- ---------- -------------------- <br /> (If of an owner) <br /> FOR DEPARTMENT -USEqNLY ; <br /> APPLICATION ACCEPTED BY ------- ---- - ------•- ----- - -----../--/�-�.--- --- - -`.-t9i.-. DATE .... ..'..l.G.----�'•------------------- <br /> BUILDING PERMIT ISSUED ------------------ / -- -- - DATE <br /> ADDITIONAL COMMENTS ------------------------------- <br /> .. -- ------• .............................................................-........................................................... .. ----..............---.....................---..........-- <br /> ......................... ------------------------- ------------------------------- -----------------. ----- ---- . - <br /> - <br /> -- . ----- - <br /> ------ ---- ..................... - -- <br /> ---- ----- .. ------------------- --- ---------------- <br /> Final Ins <br /> --Date ..---Inspection by bY - <br /> SAN JOAQUIN LOC,, LitALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />