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FOR OFFICE USE• <m .• <br /> *:APPLICATION FOR SANITATION PERMIT <br /> °. Permit N <br /> r/ <br /> -- ----------- - --------- ----•--------- - - - � o: w _l._ <br /> (Complete in Triplicate) ---"7� <br /> ----- <br /> - --------------------------------------------- <br /> --------------- ------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for 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 /> � f <br /> JOB ADDRESS/LOCATfON .. _ lY /�-- --------- - � y CENSUS TRACT + <br /> Owner's Name _ya-C114��Y �'�o I <br /> = Phone <br /> I Y . <br /> Address -------- ------ =-- ------------ CSC lv # _ <br /> - ---•------- - -----------------_-------- -- -----. city ---�-�---- ------------------------------------------------ <br /> 6"-- --------r-�/� <br /> t <br /> Contractor'-,3 Name ...� s .. 4jG---______-� - --- __-.License # =I _ /3 Phone <br /> - ------- - - .-b.-b------ � ----------------•-- <br /> Installation will serve: Residence ❑ Apartment House <br /> ❑ Commercial Trailer Court ;❑ I <br /> Motel ❑ Other -- ------------ ---------------------------- <br /> Number <br /> ----------- ------Number of living units------------- Number of bedrooms ____________Garbage Grinder ----- Lot Size ______---x----------------------------------- <br /> WWater ----_r_________________- <br /> ater Supply: Public System and name --------------------------------- --------------------------------- ---------------------------------a."'---Private ❑ i <br /> Character of soil to a depth of 3 feet Sand'❑ Sift❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay. Loam <br /> P ❑ ❑ ----- If Yes, type ------ ------- ---L------ -- <br /> ,Hard an Adobe Fill Materia! _____.: <br /> - i <br /> (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed ton reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ) Size------------------------------------------------ Liquid Depth -_------------------------ <br /> CapacitY 'i------ --------- Type -------------------- Material------ --------------- No. Compartments ' ' ---------- <br /> Distance to nearest: Wel! ------------------------------------Foundation ---------------------- Prop.Aine --------------- ....._ <br /> LEACHING LINE [ j No. of Linesg <br /> ----------- - - --- Length of each line_ -------------------------- Total Length '•-------------•------•--•-- <br /> D' Box -__'_�_.___ Type Filter Material ____________________Depth Filter Material __------_-___-___ ------------------ <br /> •__•_ ' <br /> Distance tolnearest: Well -- --------------------- Foundation ___ Property Line <br /> ----- ------- <br /> SEEPAGE PIT [ ] Depth -------_------_----- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth --------------------------------------- <br /> - ------Rock Size -------------------------------- <br /> ��. <br /> Distance to nearest: Well ----------------------------------------Foundation .----------_-a_.---- Prop. Line -------;-;Q ......... C <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---•----=----------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---- ---------------------------------------- --------------------------------------------- -•--------------,•--------------------'---- <br /> os <br /> Dis al Field S Require 00 10 __ly__ —./6w----P (Specify Re q s� cif -- ��Y ------------ + <br /> & - -------------------------------------------------- -------- ----------------------- ------------ <br /> - ------------------- -------------------- -------•--------------------- <br /> I <br /> (Draw existing and required addition on reverse side) # "' <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaqui <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- p <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 personin such manner <br /> as to become subject to Workm 's Compensation laws of California." <br /> Signed -------- - ---------- -- --- -------° <br /> - Owner <br /> BY ` <br /> - ----------------------- --------------------------- ------------------------ as <br /> a <br /> Title ------------------------------- <br /> (If other than owner) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . _ ___ __________ <br /> ------------ - ------------------------------ - ---------. DATE ----------------•-------- - - ------------ <br /> BUILDING PERMIT ISSUED ----- ------------------------------------------------------------------------- - -----------------------DATE ----- ---- ------ <br /> ADDITIONAL COMMENTS <br /> ----------- --------------------------------- ----------------------------------- ----------------- <br /> --------------------------------------------- <br /> ------------- ------ <br /> - r <br /> Final Inspection by: 4 -- ---------------------------------------- ------------ Date ----� ---- -- -------- <br /> SAN, JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1 '68 Rev. 5M /.6- 1141Z- <br />