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FOR OFFICE.USE: APPLICATION FOR SANITATION PERMIT <br /> V <br /> ---------- ---- y- ----- <br /> Permit No. -. - - <br /> ---------- (Complete in Triplicate) <br />------ -------------------- ------------------------------ <br /> Date Issued -------------------- <br /> This Permit Expires 1 Year From 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 /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> -----------CENSUS TRACT -------------- ------••--- <br /> JOB ADDRESS/LOCATION _�-- -----i---� -- -��- ; <br /> Owner's Name ---------------------------------_--------------- ---------------------Phone ------------------------------------ <br /> .y��.�,`�/! -----fes ----�----- /-)- <br /> o - °T /A_!+l L .`/II,/_u F__ ------------ city 57-X?--C��cTD�--���l L - <br /> Address ----- -- ------ �. � :--° ` <br /> 41 <br /> Contractor's Name ��1 1 '. � {�` i�� : License # - . Phone <br /> Installation will serve: Residence [V Apartment House-[] Commercial ;❑Trailer Court <br /> Motel ❑ Other -------------------------------------------- , <br /> Number of living units:---- -_- Number of bedro ms __ --------:Garbage Grinder --- �`S x�;lO <br /> - Lot Size,-- --- -- - ---------------------- <br /> I CA r<I F'O/Lscs/a GGA ----Private <br /> Water Supply: Public System and name ---==------------ ---------------------�AT��----- -�=�-�--------------'----------------- ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay �K Peat ❑ Sandy Loam ❑ Clay Loam ;❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ----_-----_---------------- <br /> (Plot plan, showing size of lot, location-of''system4 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,) O <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] <br /> Size------------------------------------------------ quid Depth ------------------------- <br /> Capacity <br /> -------------•----- -Capacity I---------------- Type -------------------- Material---------------------- No. Compartments ------------_-- --= <br /> Distance to nearest: Well ------------------------------------Foundation ------------------- Prop. Line -------------•------- <br /> LEACHING LINE [ ] I ----- Total Length ------.--- <br /> No. of Lines Length of each line ------------- <br /> 'D' Box --1.1------- Type Filter Material --------------------Depth Filter Material -----------------------------••-------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -------------------r--- <br /> SEEPAGE PIT [ ] Depth ----': ------------- Diameter ---------------- Number -------- ------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------- ----------- <br /> - ---Rock Size -------------- ----------------- <br /> Distance tonearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- # <br /> REPAIR/ADDITION(Prev. SanitationPermit# -------------------------------------------- Date ----------------------------------) <br /> i <br /> Septic Tank (Specify Requirements) ---------------------- -------------- - - ------------------.----------------------------E <br /> EY ' <br /> Disposal Field (Specify Requirements) ---4/V------------•-- ------- <br /> ------------------------------------------------------------- ------------------------ <br /> ---- -------------------- ------------------------------ - <br /> -------------------------------------------------------==--------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 liven- <br /> . j <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the worIV 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." i <br /> Signed ... ---- - ------- Owner <br /> --- --- - ----- //� <br /> BY <br /> ..� Title A'.(��i! f- C-�-------- <br /> (If othe t n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- ---- ------- _.------ _-- DATE - 32-� �? ------------------ <br /> ----- ---------------------------- <br /> BUILDINGPERMIT ISSUED -----------' --- ------------------------------------------------------------------------------------ ---DATE -- - ---- - - i <br /> ADDITIONAL COMMENTS -------------1---------------------- ------------------------- <br /> -------------------------------------------------------- <br /> --------------------------------------------- <br /> k[ -- -- --------------------------- ------------- -,' --------------------------------------------------------------------- <br /> i <br /> ------------------------------------ ---- - -- --------------- - <br /> Final Inspection b Date ---- - --- ----------- = <br /> SAN JO QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M �/ <br />