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FOR OFFICE USE: <br /> ' APPLICATION FOR SANITATION PERMIT <br /> ----------------------- --------- --------------- i e - - <br /> S~5� <br /> (Comlilete in Triplicate) Permit No: <br /> ---------- --------------------------- <br /> ------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> - A <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 /> .1 <br /> JOB ADDRESS/LOCATION . $,-� ------W­-MA -UJFLU-_RA?-----------------------------------------------CENSUS TRACT -------------- ----------- <br /> Owner's Name --------------------------- ------------ ------Phone -------------------------------•---- <br /> -------- 1 _[2�s-c ++� <br /> Address - ------- -----n o t---- City - ! -C fi <br /> - ------------------ -------- <br /> t <br /> Contractor's Name �— <br /> "�Q�+4�A.1� ---------------------------------------------------License # ---------:�'----- Phone ------ - - -- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> / Motel F-1Other ------------------------------------------ {{,, <br /> Number of living units:-------!___ Number of bedrooms ----f�____Garbage Grinder _Te- ---- Lot Size -_5-LA__________________________________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------- --------------------------------Private ( � F <br /> i <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay Loam .E] <br /> -� Hard an Adobe Fili'Nlaferial" <br /> p ❑"� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �. <br /> A �- <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] Qb. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -----------..--------.----- Q <br /> Capacity J------- ---- Type -------------------- Material---------------------- No. Compartments ---------•---..._...._ ` <br /> Distance to nearest: Well ___________________________________Foundation ---------------------- Prop. Line -------------------- <br /> LEACHING <br /> _-__._- _-:_-----LEACHING LINE [ ] No. of Lines ---------- Length of each line-------------------------- Total Length ___________ <br /> 'D' Box --- ------- Type Filter Material --------------------Depth Filter Material -------------------_---------.----.-._.----- <br /> ._.. <br /> Distance to nearest: Well ___"____________________ Foundation ._____________________ Property Line ______ ___._._._.___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ----------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth --------------------------- --------------------Rock Size --------------------------••---- # <br /> Distance to nearest: Well -----------------------------------------Foundation -------------- ---- Prop. Line __.----------._.-.-_._ <br /> REPAIR/ADDITION(Prev. Sanitation 'Permit# _____________�_.____________________"_____ Date _______________________-____ <br /> I <br /> Septic Tank (Specify Requirements) -------- �(0 ------------------------------- -------------- - <br /> 'I c� <br /> Disposal Field (Specify Requirements] ------OC- b--------------••----------- ----------------------------------------------------------------------- ----------- <br /> - <br /> - ---- – _ ---_ �– ---- <br /> {Drow 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 <br /> �subject t Workman's gCoens ion laws of California." <br /> Signed �l ?-`-- -------- ------------------------------ Owner . <br /> BY - ----------------------`-1-- - - ------- Title ---------------- <br /> ---------------- <br /> - ---------------------------------- <br /> (If other.tHan owner) <br /> FOR .DEPARTMENT, USA ON <br /> BUL DINGION ACCEPTED PERMIT ISSUED ---_--- ---11-------- --- -_. DATE <br /> --------- <br /> ----------DATE ---------------------------------------- <br /> ADDITIONAL COMMENTS ---"--------- ) ------------ -------- --------------------------------------------=-----t - -------•---- <br /> -) - <br /> r <br /> - --------------------------------- -------------------------------------------------- <br /> ------------- --------------------------------------------------------------------`-- ------ a - <br /> Final Inspection b ------ - - - ---------------"-------- --te ----- <br /> p Y ��� -- . . Date --- <br /> Final <br /> SAN J A IN LOC EAT DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />