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FOR OFFICE USE: � <br /> " APPLICATION FOR SANITATION PERMIT <br /> ----------Y---------------------- = �� l <br /> Permit No: _ -- --.-.- <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- This Permit Expires 'I Year From Date Issued Date Issued_-c�-�._:�� <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 /> JOB ADDRESS/LOCATI N . --d-- --------- 4,1 ---- <br /> CENSUS TRACT <br /> Owner's Name -- � ------------------ -------------------Phone --------------------------- <br /> Owner's <br /> -g-7d$ <br /> Address ---- ---------------sem `'`' '--------� � ', ------------- Cit <br /> Contractor's Name --------------- __-__-____ - _ _ -_--__.___---__ ;/.License # 6-:��_ Phone <br /> Installation will serve: i Residence ['Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other-------------------------------------------- <br /> Number of living units:_____- -- Number of edrooms _.___ ___ arbage Grinder {v.c�-- Lot Size __ 00 <br /> Water Supply: Public System and name __ ----- -----------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeX 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 -- ----------- ------ Type -------- t ------ 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 --------------------.-----._.___----------._ <br /> Distance.to ne6rest: Well ------ ------------- --- Foundation ------------------------ Property Line -__-_.-_--_-. <br /> SEEPAGE PIT [ ] Depth ----------- ----r__- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------- ----------------------------------Rock Size -------------- ----------------- <br /> Distance to nearest: Well ----------------------------------------Foundation _________________ Prop. Line _.______-_______._f__ <br /> REPAIR/ADDITION(Prey. Sanitation Permit F# ------------------:-- y <br /> ---------------- <br /> Date --_- -- ----------------------- � <br /> Septic Tank (Specify Requirements) ---- `�' � - r` <br /> Disposal Field (Specify Requirements) r- : - � ` -----{ ` - -------- p �`- ---- <br /> - -------------------------------------------- <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. glome 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 ---- --------------------------------------- <br /> ---- <br /> -------------- -------- - Owner <br /> BY - --------------------------------------- Title ..�-.�/='---„�------- -- <br /> -------------- r <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _1T DATE �� _--._-_---- - <br /> --------------------.--_--_-_---___.-_-_-----__----_L_--_-_____._ ._.__.___ <br /> BUILDING PERMIT ISSUED ---------------------------------------------- ----------------- --------------DATE ---------- ------------------------------- <br /> ADDITIONAL C� <br /> 1 f <br /> ` <br /> --- ------ <br /> ---- --------- -------- - <br /> 4- �� ------- <br /> F -- ----------------------------- ------------------ -------- <br /> ------- <br /> F Y -------------------------kDate y7Q- ------- <br /> - ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 <br /> '-11 68 Rev. 5M t L <br /> _ 4• <br />