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FOR OFFICE USE: , 7 <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Tripliiate) Permit No. ____l�U�' <br /> -------- I-- --- -------- ------------ ----------------- vj <br /> This Permit Expires 1 Year From Date Issued Date Issued _1�__��_�o <br /> - - - - - - ----- I 0 302}O�-3l <br /> Application is hereby made to the San Joaquin Local Health District for Z -- <br /> a permit to construct and install the work herein <br /> described. This application is made in complignce^with County Ordinance No. 549 and existing Rules and Regulations: <br /> - � r2- N• M� �_ .dl <br /> KKJOB`ADDRESSLOATION J- _ a:►c._F,c --"--.r� -_` 4� +�t-/_CENSUS TRACT -------------------------- <br /> Owner's Name `'�_ -- -------------------------------- ----------- -------------------- Phone -- --------------------------------- <br /> Address ----- 't �` � 3*, ------------- --------------- - =_ - -------- City ---_ �r�i ---------------------------------------- <br /> Contractor's Name ---------- - --- - - -------''--�-lzr r .___ -_---.License # Phone ------------------------------ <br /> Installation wilkserve. Residence ❑ Apartment House,[:] Commercial' Trailet'Court i❑ <br /> •� - Motel ❑ Other ------- L-A-..---- <br /> "may... <br /> Number of living uri t --_/f Number of y edrooms ______Garbage Grinder ------------ Lot Size ----- -- --- <br /> Water Supply: Public System and name - _ _ Private PT <br /> - --------- - ---------------------------------------------------------------------- --- <br /> Character of soil to a depth of 3 feet Sand'❑ y Silt Ciay .❑ Peat❑ Sandy Loam--F Clay Loam :❑ <br /> .Hardpan ❑ Adobe E]• Fill Material ------------ If yes, type --------------------------- <br /> I <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �] <br /> i /! i F <br /> PACKAGE TREATMENT I ] SEPTIC TANK f / Size-16991---- `_ --------------- Liquid `Depth <br /> Capacity _� b_�____ ___ Type ° -Material_ ENo. Compartments __ ---------- <br /> VV ' <br /> Distance to nears . Well _____________d`d------'+E'___-Foundation --------14_t__c_ Prop. Line --------------------- <br /> LEACHING LINE [ f-l"'No. of Lines --- ------------- Length of each line.--,F ---------------- Total; Length _«4�-_f------------- 'E <br /> 'D' Box Type Filter Material ---------Depth Filter Material!----/,I_ ----------------- <br /> `-___._.:..-_ , <br /> Distance 3 nearest: Well -----.Fp- Foundation __________ Property Line --_r_________________ <br /> SEEPAGE PIT [ ] Depth I <br /> -------------- Diameter ---------------- Number ---------------------- ---- .Rock Filled Yes '❑ No i❑ <br /> 1 <br /> Water Table Depth <br /> ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> --- --------------------------Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop! Line ---------------------- - � <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ___-_________________________-} ' <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ------ <br /> r <br /> Disposal Field (Specify Requirements) -----------: - ----------------------------------- ----------------------' <br /> --'--- --------------------•--------------- <br /> --- ---------------------------------------------------- I---------------------- ------------------------------------------------------------ ------------ ---------------------------------- -- --- <br /> --------------------------- <br /> ----------------------- --------------------------- -----------------------------------------Jr --------'------- f <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 shall not employ any person in such manner <br /> as to be m subject to WorkmanYCompensation laws of California." } <br /> Signed ------- -- -------------------------------- <br /> By <br /> ------------------------------ Owner t <br /> B ---- �� - ------- <br /> Y z ` ---------------------------- Title <br /> (If other than owner} ' ,k t <br /> oe FOR DEPARTMENT USE ONLY` <br /> APPLICATION ACCEPTED BY _-_-- - -------------- ----------------------- DATE - �' -.-_ _ --- <br /> ---- f <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------=---------------------------DATE ---------- ----------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- -------------- ------ <br /> i i <br /> t <br /> ------------------------------------- - ----------------- --------------- --------------- -------------------------------------- ----- <br /> Final Inspection by - -------------------------------------------------------- --------Date �. --._ -------t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> E. H. 9 1-'68 Rev. 5M <br />