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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------- - --- ---- -- - - . 7aa <br /> (Complete in Triplicate) Permit No <br /> ---------=----------------------------------------------- <br /> ' 3- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued 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 Regulation/s: <br /> JOB ADDRESS/LOCATION .---- 4--f----�--------�Q- � ^�1-----------------�-�- --'---CENSUS TRACT ----�j-- -�L_-_---- <br /> Owner's Name �� af � r'?'� =� ( _ "C' _:_ I� - Phone _ "fi ,3� <br /> �s r <br /> Address ------ L- 3 �1{ -��1!�F Cityf <br /> Contractor's Name ----C9yf L` ��--------- License # �C7�G Phone 3 ------- <br /> Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court ',❑ <br /> JMotel ❑Other ------------- ------------------------------ r <br /> Number of living units:-----L.---- Number of bedrooms _ _-.Garbage Grinder Lot Size <br /> Water Supply: Public System and name -------------------------------------------------------------------- ------------------------------- ---------Private <br /> Character of soil to a depth of 3 feet: Sand�r Silt❑ Clay ❑ PeatSandy Loam F1Clay Loam [IHardpan E] 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 public sewer is available within 200 feet,) • 0 <br /> PACKAGE TREATMENT [ I SEPTIC TANK-[ ] Size------------------------------------------------ Liquid Depth ______--__----_-__--..._-- ',,A <br /> Capacity ----------------- Type -------------------- Material---------------------- No. Compartments ----------------•----- <br /> Distance to nearest. Well ------------------------------------Foundation --7------------------- Prop. Line --------------____.... <br /> LEACHING LINE [ ] No. of Lines _._____:/_--__-_--___ Length of each I'ne-_---/ '� K f <br /> _ Len _ _�-------------- Total Length _-f�--�-----_-__-- <br /> tti r Ir <br /> D' Box - __::_____ Type Filter Material -�-______________ Depth Filter Material __ . ___________________________________ <br /> --- Pro -. <br /> Distance to nearest: Well ------ ---- Foundation - ------ party Line, -_� ______._.... <br /> SEEPAGE PIT [ ] Depth ----------------- Diameter ----------------- Number -----.---------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line _--__.---_-___..__.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------- -------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------- ----- t---------------.----- ----------------------------------------•---- <br /> Disposal Field (Specify Requirements) -----D!_ST--------Roo---------------10Q------------LEA-04 ---2--JA/r—` <br /> --Lj A/r ---------------------- <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 subjee tt to Work n's Compensation laws of California." <br /> Signed 1 ` ' <br /> ------------------ ----------f-- <br /> ---------- Owner <br /> ---- - -- <br /> BY = �' -----------—C------------ Title -------- ---------------------- - - ----------------- <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY �1 /q <br /> APPLICATION ACCEPTED BY -- F(-R---D-------------------------------------------------------- -------------------- DATE -..-1�-- ���-� --------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------ ---------------------------------------------------DATE ------------------------ ----------------- <br /> ADDITIONALCOMMENTS --------- ------------------------------------------------- ----------------------------------------------------------------------------- ----------- <br />- ------------------------=---------------- --------- --------------P­Id- <br /> -- ------------------------------------------------------------------------------------------------- -- <br /> -------------------------------------- -- ------ ----------------- -- ------------------------ ---------------------- -- ---------------- ------------ 9----------------------------------- --- ---- - -- -----------------------------------------------------;" /Final Inspe 'on by: ---- - --- ------------ -----Date ---- r <br /> .... ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />