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F <br /> FOR OFFICE USE: <br /> APPLICATION FOR-SANITATION PERMIT <br /> ------ i Permit No: <br /> (Complete in Triplicate) <br /> _____._____________________________________ - This Permit Expires 1 Year From Date Issued <br /> Date Issued __--//S ?/. <br /> ------------ - <br /> Application is hereby made to the San Joaquin Local Health District for a per 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/LOCATION . // Qr'� C�_ fit - --------- --------- ------------ :----CENSUS TRACT _------------------------- <br /> r <br /> Owner's Name -------:-TV✓ ----------- ------f------ -----Phone <br /> Address ----- k,.-<L-0L_--,'y--_-_11---- - —---- ------- ----------------------------------- - ------ Cit --------------------------------- <br /> Contractor's Name --1_Q _G �`- -----��`Q_ -t--_---_____sf- _.License # -_ 4k?mss Phone - f 4AP <br /> '7�F- <br /> Installation will serve: Residence iV Apartment House❑ Commercial :❑Trailer Court [I <br /> r <br /> Motel E] Other --------------------------------------------- <br /> Number <br /> ------------- --------------------------- <br /> Number of living units:_J______ Nulber i <br /> of bedrooms _______Garbage Grinder _ Lot Size <br /> Water Supply: Public System and name'--------------------------------A-------------------------------------•---------------------•-----•----------•Private <br /> Character of soil to a depth of 3 feet: .Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam:❑ <br /> Hardpan ❑ Adobe Fill Material ------------ If yes,type -_-___-________________- i <br /> r <br /> (Plot plan, showing size of lot, location of,system in relation to wells, buildings, etc. must be placed on reverse side.) N. <br /> NEW INSTALLATION: <br /> .(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> 'i 1 <br /> PACKAGE TREATMENTr [ I SEPTIC TANK [ ] Size------------------------------------------------- Liquid .Depth ------------------------- 4 <br /> Capacity _.:_1--------------- Type _-------------------- Material---- ---- No. Compartments ....................... <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ---------------r_____- <br /> LEACHING LINE No. of Lines -------I------------- Length of each line--------A/ ----------- Total Total Length ---"__-- --------_--- <br /> 'D' Box ---/r-------- Type Filter Material --------____ __-"-.Depth Filter Material --------,�_l�___________________________ <br /> Distance to nearest: Well --- ------_--_- Foundation ----��____________ Property Line. - __ _________ <br /> SEEPAGE PIT L)1] Depth ___- Diameter ___ `_____ Number -____-____ -------------- Rock Filled Yes g No i❑ <br /> Water Table Depth ---------- -----------------------------Rock Size -------- --__--_Y__•____------ r <br /> Distance to nearest: Well ------ _______________Foundation ______ Prop. Line ___ ....... <br /> REPAIR ADDITIO (Prey. Sanitation Permit# _______ - ---------- ________________ Date.._.-----------_.___--______________) <br /> i <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------- ------------•- -----------------------­--- f Field (Specify Requirements) ------------ ------------•__-------------------------------------------------------------------------------------------------------- # <br /> ----------------------------------------------------------------------------------------------•---------------------------------------------------------------------------•--•--- •-•---•----------•--•-- <br /> I <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 subject to Workman's Compensation laws of%California," <br /> Signed ---- --------------------------------------------------------------------------------------- --- Owner <br /> BY ------- ---rs�--- ----`3' ---- -------------------- Title _-- - <br /> (If other than owner[ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----C_=- ----- ----- f DATE __.. ^3 <br /> BUILDING PERMIT ISSUED ----- -- ----- .............................=-----------=--DATE ------------------•------------------------ <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------- <br /> i <br /> ---------------------------------------------------------- -- --- <br /> ------------------------------------------ <br /> -- C Final Inspection by -------------------------------- ------------------ ----------------------------- --Date ----------- --- --- ---- <br /> - . <br /> SAN J AQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'6$ Rev. 5M f <br />