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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> =" Permit No. <br /> ------------- <br /> (Complete in Triplicate) + <br /> 4. <br /> ---------------------------__________________________ <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to t San `quin Local Health District for a permit to construct and install the work herein <br /> described. This application �s m de in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO. —`- --- -'- 'P 1' /,''� <br /> " -__CENSUS TRACT --------------•-------.--- <br /> / Phone----- ------ <br /> ane <br /> Owner's Name -------- --:',A,-�-L'- "--=-�'-�--- � t _ l <br /> City - ----- - - -------- ------------------------- <br /> Address ---.-- -- '-�-= - --------- ------- ----•-------- --- ----- ----- -- -------------• - _ <br /> 49 <br /> ' {", License #c r..`-----` Phone <br /> Contractor's' <br /> Name - r _ �4 ------ �-------- � �� - <br /> Installation will serve: Residence ❑ Apartment House�❑ Comniercial iXTrailer Court ',❑ <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:__r-- ----- Number of bedrooms --_-________Garbage Grinder ------------ Lot Size -------- <br /> i -- - • <br /> Water Supply: Public System and name ------------------------------------ --------------------------------------------------------.._Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt.f] Clay E] Peat El Sandy Loam Clay Loam E] <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 eublic sewer is available within 200 feet,) U1 <br /> PACKAGE TREATMENT f I t.SEPTIC'TANK �6��Size__�_:�._?E_`�X.�r l�._ -�-------_- Liquid Depth ___.. --------- <br /> Capacity .40C_7----- Type Material_det1 L-fk-,,-T No. Compartments Z--________________ <br /> Distance to nearest: Well ------------------------------------Foundation ------------------- Prop: Line ----------------------- <br /> LEACHING LINE [ ] No. of Lines ...�_---- Length of each line-_______j _____+ Total Length :____'-_, �-�--_.___. <br /> `D' Box - ------ Type Filter Material --------------------Depth Filter Material -------- f-_R-1_'------------------••--- <br /> Distance to nearest: Well -3-62-P__ Foundation Property Line __..-IS-_____...,.__ <br /> SEEPAGE PIT [ ] Depth -___ ------------ 17iameter ---------------- Number ---------------------------- Rock 'Filled Yes j No i❑ <br /> Water Table Depth ----------------------------------------------Rock <br /> Size -------------------------- ......_- <br /> Distance to nearest:.Well ----------------------------------------Foundation -------------------- °Prop. Line ---------.____•------- <br /> REPAIR./ADDITION(Prev. Sanitation Permit# ------------------------------------ ------- Date --------------.--------------=----1 <br /> Septic Tank (Specify Requirements) -------_:_ ----- ------------------------------------t.----------------------------- <br /> Disposal <br /> ---------------------- ----Dispasal Field (Specify Requirements) -------------------------------------------------------------------------------------------------`----------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> + <br /> ------------------------ <br /> ---------------------------- } <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. 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 object to Workman's Compensation laws of California." <br /> — - <br /> k Signed -------- �-- I �c~r ,---- dlc?----------------- • --- Owner <br /> BY ---------------------------------------------- ------------------------------------------- Title --------- -------------------- ---- ---------------------------------- <br /> (If other than owner) a <br /> FOR DEPARTMEN USE ONLY <br /> APPLICATION ACCEPTED BY - -- ------- ---- ti --------- ---------- DATE ---- -------7 <br /> - r <br /> �------------- <br /> BUILDINGPERMIT ISSUED ------------------------ ------•------------------------------- --------DATE ------------------------------------------- - <br /> ADDITIONAL COMMENTS --------------------------------------------- ------------------- <br /> I --------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- <br /> r --------- --- -------------------------------------------------------------------------------------- -------------------------- ----------------------------- --------- ----------- ----------- <br /> - <br /> �. <br /> - ----------------------- --- - <br /> Final Inspection by. -------- - ..Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />