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FOR OFFICE USE: !�• ��� <br /> �$a APPLICATION FOR SANITATION PERMIT <br /> --------------------- ------------•-- ----------- t-- <br /> S�6 <br /> (Complete in Triplicate) Permit No. <br /> ------------ - -------------- ti <br /> Date Issued <br /> This Permit Expires 1 Year From Bate Issued <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',,' m <br /> copli• d witunty Ordinance No. 549 and existing Rules and Regulations: <br /> w .,40-4-CENSUS TRACT -------------- ----------- <br /> JOB ADDRESS/LOCATION -- ,�-- -0�,- <br /> Owner's Name !! Phone -------------------------------•---- <br /> Address17p �. ------ ------------------------------------- City -------------------------------------------------- <br /> �e� License # 1.0 '1?J' ---- Phoney '3-_ <br /> Contractor's Name _& .. -- <br /> j ---. <br /> Installation will serve: 4 Residencer Apartment House❑ Commercial :[]Trailer Court ❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units:_-------_ Number of bedrooms ________Garbage Grinder --.-.- Lot Sizer--077.•----------------- <br /> Water Supply: Public System and name _h__F -__ ------------------------------------------------------------------------Private E]I <br /> --- ------------------- <br /> Character of soil to a depth of 3 feet: Sand'E] Silt fl Clay ❑ Peat❑ Sandy Loam 21 Clay Loam ❑ <br /> IHardpan ❑ Adobe'E Fill Material ------------ If yes,type __________________________ <br /> ' must be laced on reverse side.) 6N <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. p <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 4 , <br /> PACKAGE TREATMENT ( ] SEPTIC TANK k] <br /> �. L' p <br /> Size�-t-f " ----- --------- quid Depth ---------- -- - <br /> Capacity r DA--------- Type r Material4 ----- No. Compartments --le-------------- � <br /> Distance' to nearest: Well -SQ- ---------------------------Foundation�B_'.-______------ Prop. Line -ts_-_______..------ <br /> LEACHING LINE [ ] No. of Lines l'y____ _____________ Length of each lineA.---- -p "-7D Total Length Xd____-______._._.__ <br /> 'D' Box -__-_....4- Type Filter Material ____________________Depth Filter Material _.___..___________----------•---_-.--.------ . <br /> Distance to nearest: Well __sSQ_'-�___________ Foundation _.!__4"--------------- Property Line `�___.__-.____-..•___ <br /> SEEPAGE PIT [ Depth Diameter ________________ Number ------------ --------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ---------------- --- Prop. Line -----_-------------•- <br /> REPAIR/ADDITION{Prev. Sanitation i Permit# -------------------------------------------- Date --------------------•--------- <br /> ---) <br /> i P <br /> Septic Tank (Specify RequiremenI s) --------------- -------------------------------------------------------------- -----------------------------•-------------- ------------ i <br /> Disposal Field {Specify Requirements) --------- ------------------------------------------------------------------------------- <br /> ' --------------------------------------------------1­1-------------- --------- <br /> ----------------- --------------------------------------.-- ------- -------- <br /> ----------------------------------------------- <br /> ---- -- - - - - - ------------- ----- <br /> (Draw existing and required addition on reverse sidey <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, anW Rules and Regulations of the San Joaquin local Health District. Home owner or licen- <br /> sed 1. <br /> tore certifies the following: <br /> 1 <br /> agents nts si na g <br /> g 9 � <br /> an person in such manner <br /> "I certify that in the performance of the work for which this permit is issued, I shall notemploy y p <br /> as to become subject to Workman's Compensation laws of California." <br /> t Signed --. Tl «p�ner <br /> BY ------ ---- �-- -- ---- --------------------------------- Title ------------- <br /> -- -------------- ---------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY p <br /> DATE ------------- <br /> APPLICATION ACCEPTED BY -- .- _-- '_iY '�.f-- <br /> - ------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED ---------- --------------------- ------------------------------- <br /> ADDITIONAL <br /> -----------------------------ADDITIONAL COMMENTS ----------->------------ ----------------------------------- <br /> ------------------------------------------------- <br /> i ------------ ------------- - ---------- <br /> -------------------------------------------------------------------------- -- <br /> ----------------------- --------- <br /> -------------------------------------------- - - --- <br /> Final Inspection by: ------------------------------------ --------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I E. H. 9 .1-'68 Rev. 5M <br />