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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- -------------------------- Permit No. <br /> (Complete in Triplicate) <br /> ---------=---------- --- -------- ----------------------- 7 L <br /> ___ ___ __.__.__________ This Permit Expires 1 Year From Date Issued Date Issued __.,�_____'__ _ <br /> 2_Y2 — 030--33 <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 ADDRESS/LOCATION ---------- -----..----ute:Lll.f-------------- ---- <br /> - --------- -- ----------CENSUS TRACT .----------- ' <br /> Owner's Name $ hUG. ---------- -Phone � ------•-- <br /> Address --------•_---------- ------ ------------------------------------ City r� - ----------------- ------ -----------------------------•--••-- ! <br /> Contractor's Name ------------ il --------------------------------------------------=------License # R57.`2.1`(------- Phone --------•---------------...... fi <br /> Installation will serve: Residence XXpartment House'❑ Commercial :❑Trailer Court ❑ <br /> .w <br /> Motel ❑ Other -------------------------------------------- <br /> U <br /> Number of living units:.___ ______- Number of bedrooms ________Garbage Grinder -1�?_-___ 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 ❑ s <br /> Hardpan ❑ Adobe?:I 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,), , } <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ` r Siie__ __.________.__.____ Liquid Depth -_`-` �___ __________ <br /> 195 <br /> Capacity M .________ Type _____ Material__ 2` c __ No. Compartments ....... <br /> Distance to nearest: Well ------------- _9 '______________Foundation _10-------------- Prop. Line ----&s <br /> LEACHING LINE [ ] No. of Lines ------3----- ------ Length of each line_______QP--------------- Total Length -0-P <br /> Boxj?�.?____ Type Filter Material _ _ ___Depth Filter Material ----------0�---r.............. <br /> _ ........... <br /> Distance to nearest: Well ______ _� r'7 <br /> __________ Foundation -___.�_._____._.__ Property Line __ ____________________ <br /> SEEPAGE PIT [ ] Depth _______________ __ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ____.____-___-__----. <br /> REPAIR/ADDITION(Prev. Sanitation Permit s# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -- -------------------------------------------------------- --------------------------------------- ------------ - ------------ <br /> DisposalField (Specify Requirements) ------------------------------•----------------------------------------------------------------------- ---------------------------- v ► <br /> ___________________________________________________________________________________ i <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 /> has to become sub'Lect to Workman's Compensation laws of California." r, <br /> Signed --yy r--------------------- <br /> - -- - •--------------- Owner C <br /> By ---------------------------- --------------------- - ------------------------ ----------------------- Title --- - ------------- ------ <br /> f If other than owner) <br /> FOR DEPARTMENJ USE ONLY <br /> APPLICATION ACCEPTED BY ---------- - ---------- <br /> DATE ?� �T <br /> BUILDING PERMIT ISSUED ------------------------- ----------- ------------- ---------------------------- <br /> -------DATE --------------------------------- <br /> - <br /> ADDITIONAL COMMENTS ------------------------------------ = <br /> ------------------------ - --------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- <br /> •------------ -------------------------------------------------------------------------------------------------- <br /> ----------------------------- ---------------------------------------------------------------------------------------------- <br /> Inspection by: -- ------------------------------------------------------------ Date ------- `� - -- <br /> ----------------------- <br /> Final - ---- - <br /> ------------------- --------- ----- <br /> - <br /> ---- <br /> SAN JOAQUIN LOCAL HEALT DISTRICT <br /> E. H. 9 . 1-'68 Rev. 5M C?T; <br />