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FOR of ICE L1S :O-D�- APPLICATION FOR SANITATION PERMIT <br /> ---------------- (Complete in Trilplicate); ;i Permit No. _o <br /> G ---------------------------_---------------------- I 1^%,. <br /> Date Issued <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application i5`hereby\madeao-the <br /> 'de-to-the-San-Joaquin Local Health district for a permit to construct and install the work herein <br /> descri e T is application is made in compliance with County Ordinance No. 549 and a istin Rules an egu ations: <br /> j�. _•_ltd' _ - CENSUS TRACT - <br />` JOS ADDRESS/L CATION r. 1 - �--- -I11►�" t <br /> Owner's Name �----------------- <br /> 0 l 1 --- - -- .Phone <br /> ---------------/--q-------------------------- <br /> -" ---------- ,- <br /> Address © / �; Cit - - { �«---- i � <br /> --- .. <br /> b <br /> Contractor's Name ------- -- --------- -- ---� 617 <br /> -1;cense # j-� Phone ._7�a <br /> i <br /> Installation will serve: Residence ❑ Apartment House Commercial :❑Trailer Court ;❑ <br /> �/ T l <br /> Motel ❑Other ------------- - -a=---- <br /> Number of living units_____________ Number of bedrooms ------------Garbage G tfider ._.______.__ Lot Size ___-________-___________ _____________- <br /> Water Supply: Public System and name --------------------------------•------------- ----------------------------------------------Private <br /> .. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay El Peat E] Sandy Loam ❑ Clay Loam `I . <br /> Wit# v� 4 <br /> W <br /> Hardpan E] Adobe❑ `Fill terial—_A_____" --------------- <br /> 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 /> i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK Si e------- Nlxc? --------------------- Liquid Depth <br /> Capacity Ty -__s --T--: ---.----- <br /> Ccity +/. .__.__ - pe .I Material No. Compartments __+ _..�..._..... <br /> F �� / I <br /> Distance to nearest: Well —-------------Foundation ___/__0----------- Prop. Line ___ _:_':-.------ <br /> i , <br /> LEACHING LINE [ No. of Lines _.--- Length of each line___/C. ------ ------ Total Length ____- ----..---- <br /> 'D' Box -------&-�ype Filter Material _-fCb Depth Filter Material ---/- '--------------_________t....... <br /> .. <br /> Distance to nearest: Well ';Or ___.___ Foundation -- l Q______________ Property Line -----1-5 <br /> SEEPAGE PIT Depth ____ ____________ Diameter �Number -------------------- ------- Rock Filled Yes ❑ No i❑ <br /> Water3,Tab.le.RDepth .I--_``------ 1.`-----------------------------Rock Size -------------------------------- <br /> UN <br /> Distance toynearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------_--.------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _________________________ <br /> ------------------- Date --------•-•------------------ <br /> kSeptic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ---------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------ ------------------------------------------------------------------------------------•--------------- <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 shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------- Owner J <br /> - Title ------- —'��/f. <br /> By -------- r------ <br /> (If of r than owner) <br /> f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- •-_ - ------------ ------------------------------------------------------ DATE ---------------- <br /> BUILDING PERMIT ISSUED ----------------=------ -------------------------------DATE ---------------------------------- ---- <br /> ADDITIONALCOMMENTS ----------------------- -- ---------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------- ----------------------- ------------------- ------------- <br /> ----------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------- <br /> - - ---- - F ---------------- <br /> ----------------------------------------------- <br /> Final Inspection by: ------------- -y - Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />