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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> f--- `� -------------------------------- ----- �-- ----- -- <br /> (Complete in Triplicate) Permit No. <br /> ----------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued �_ _I=7C-__. <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 ADDRE55/LOCATI N•.-�� _ ___ ____ <br /> �///74 �`�' ------------------- -----CENSUS TRACT -------------------------- <br /> Owner's Name <br /> .-----------------------------------------------------------Phone ------------------------------------ <br /> Address - - - -- ------ City - <br /> -•-- <br /> Contractor's Name --- ---------------------------- ----License .. '- Phone ` . <br /> Installation will serve: Residence <br /> XApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------;:----------------------------- <br /> Number of living units----- Number of bedrooms S___---Garbage Grinder __ Lot Size -------------- <br /> Water Supply: Public System and name --------------- -----------------------------------------------------------------------------------------------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 _---___ __r__._______------ <br /> (Plot plan, showing size of lot, location'of system in relation to wells, buildings, etc. must be placed on reverse side.) �y <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public, sewer is available within 200 feet,] ! �✓ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK _ _______________ Liquid Depth-_______._____---. q <br /> Capacifiy .__ -- Type f'+ -- ___ _ _ Material -�-- No. Compartments ___ _____---__-. <br /> i d <br /> .00 <br /> Distance to nearest: Well __ ,�--------------------------Foundation _______ Prop. Line ZA�_--____ <br /> LEACHING LINE No. of Lines -----Z----_-- Length of each line___ � <br /> Len ---------- Total Length <br /> ---- -1-------------- <br /> D' Box Type Filter Materia1 0-44 Depth Filter Material <br /> i <br /> Distan a to nearest: Well -_ _j____ Foundation _147Ar_!r------- Property Line______--__ <br /> SEEPAGE PIT Depth --------- Diameter tNumber ------ <br /> -- �------ --------- Rock Filled Yes " No I❑ <br /> Water Table Depth ------- ______________________ Rock Size"�—___,,!?-r----------- <br /> Distance <br /> .___ _____Distance to nearest: Well ____________________Foundation Z, ____-_ Prop. ......... <br /> REPAIR/ADDITION(Prev, Sanitation Permit* _______________r_------------------------ Date --------------------....__________) <br /> SepticTank (Specify Requirements) ---------------- ------------------------- ---------------------------------------------------------------,---------------------------- <br /> DisposalField (Specify Requirements) --------------------- ----------------------------------------------------------------------------------------------------------- <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 perfo''rmance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compen tion laws of California." <br /> Signed ---------------------- - -- --------------- ------- ---- ---------------------------- Owner <br /> BY -------------------•----------- - ------- - ---- - - ---------= --------------------- Title ------- E rf_97 ' `------------------------------ <br /> (If of than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... <br /> 1�_N V&e ------------------ DATE ---- O �- � ( <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------------ ---------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------- ----------------------------------------------- --------------------------------------------__---------------- <br /> ..------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- -- ------ ----------- ------------------------------------------------- --------------------------------------------------------------------------- ---------- <br /> --------- -------------------------•� - f/� <br /> ---------------------------------- ---- -- ---- - - -- - --- --- ------ - -- - <br /> Final Inspection by: Date <br /> -- - - - - - - - ------------ <br /> SAN J AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M ``� <br />