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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No. -- ------------------ <br /> ----------------- -----•-------------- -------- <br /> (Complete in Triplicate) <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 Regulations: <br /> JOB ADDRESS/LOCATION .-----/ -rF ........ h�'it ---- t -----,�Q-lf e; ---------------CENSUS TRACT -------------------------- <br /> Owner's NameX14! --j1d1VdF:: IA-1114-- ------------------------------------------------------------------------- ---Phone <br /> Address -----------I -4�1--C-------Allef -A-4,V4=------------•--. City -...... j ---------------------------------- <br /> Contractor's Name - ------ - ------ - <br /> _... ----------------- -------License #�w Phone <br /> Installation will serve: Residence W Apartment Nouse 10 Commercial ❑Trailer Court <br /> Motel ❑ Other --- ------------------------------ <br /> Number of living units:--�------- Number of bedrooms ________Garbage Grinder ___________ Lot Size ____ !'�^--- �` r <br /> --------- ------•---------- <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 W 4 <br /> Hardpan ❑ 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 per 'tied if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTF��neci <br /> ?st.' <br /> /[� Size_______________ __ Liquid Depth ______ <br /> Capacity Pe C l Material No. Compartments <br /> DistanceWeil ------------------------------------Foundation ---------------------- Prop. Line -----------------_---- <br /> LEACHING LINE [ ] No, of Lines ________________________ Length of each^line---------------------.------ Total Length ___________-_______________. <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Materia! -------_--__-.__---_._.__.------------..__ <br /> Distance to nearest: Well ________________________ Foundation ---_ ------------------- Property Line ____________._..__,_.__. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------- . Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well _______________________________________Foundation -------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ________ ___________________________________ Date ________.__________..._._.._......) <br /> Septic Tank (Specify Requirements) -- I----------------------- ----------------------------------------•-------- ------------------------ --------------------------- <br /> Disposal Field {Specify Requirements) y L-�`�• ! ' a -- -1_----;,:�Cr------------------------------------------ <br /> i <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 willbe done in accordance with San Joaquin <br /> County Ordinances, State Lfiws, 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 subjectW rkma ' ompensation laws of California." <br /> Signed ----- �� --------------------------------------------- -----. Owner <br /> By --------------------------------------- --#�-------------------------------------------'`1------------ Title ----------------------- <br /> (If other than owner) <br /> F1uPDEPARTMEfV .lJSE ONLY ' <br /> APPLICATION ACCEP ED BY -----1��------ --- ----------------------- -- --------- <br /> DATE f ---------------- <br /> BUILDING PERMIT IS UED ------------------------------------------ - --- ----------- <br /> ------------------------------DATE ----------------------------------------•--- <br /> -- - ------ <br /> ADDITIONALCOMMENTS -------------- ------- ------------------•- ---- --- ------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------- ----------------------------------- <br /> - <br /> ------------------------------------------- ------ ----------- <br /> Final Inspection by: -------- -- ------------ ------------------ ----------------------------- ------ -----------Date ------/�Z�-- <br /> SAN JOAQUIN CAL HEALTH DISTRICT <br /> l <br /> E. H. 9 1-'68 Rev. 5M <br />