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FOR OFFICE USE: <br /> -------------------------m------------ ---------- ------ APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------------- (Complete in Triplicate) Permit No, <br /> --------------- ----- <br /> - ----------------- Thi's Permit Expires I 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 I made in compliance with County Ordinance No. 549 and existing Rules and�Xeglqtions- <br /> -;7/ - <br /> AT zl-P <br /> JOB ADDRESS/LOCATI ------- --- ------------- ---- <br /> Owner's Name -------- -------------— _jCFNSUS. YRAdT -------- <br /> ------ --- ---- ----------------------------------------- --------Phone <br /> Address ........... <br /> --- -----I- ---------k--------?I----------------------------- ------------------ Ci <br /> Contractor's Name ----------------------------------------------------------------------------------- ------License # -----_----------------- Phone <br /> Installation will serve; Residence 0 Apartment House-[:] Commercial MTrailer Court iejvG;�, 2- 3� <br /> Motel E] Other 2_s� 2- <br /> Number of living units:,..k---- Number of bedrooms ------------Garbage Grinder ------------ Lot Size <br /> Water Supply, Public System and name ----------- <br /> ---------------------------------- ---------Private <br /> Character of soil to a depth of 3 feet, Sand[] Silt clay Ej peat Ej Sandy Loam - lay Loam 0 <br /> Hardpan Adobe 0 Fill Material ------------ If yes,type ---------- ------------------ <br /> (Plof 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 feetj <br /> PACKAGE TREATMENT SEPTIC TANIC Size-----I------------------------------ ---------- - Liquid Depth -------------------------- <br /> Capacity ------ ------------- Type -------------------- Material---------------------- No. Compartments -----------_-------- <br /> Distance to nearest: Well ---------------- -------------------Foundation ---------------------- Prop. Line ---------------_----- <br /> LEACHING LINE No. of Lines -- --------------------- Length of'each line,--------------- ------------- Total Length -----------------------_-- <br /> 'D' Box ------------ Type Filter Material -----------------:---Depth Filter Material I---------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ---------------------— Property Line ------------------------ <br /> SEEPAGE PIT Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes El No <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) <br /> ------------- <br /> peci y eq <br /> Disposal Field (S R uirements) --------6 41� <br /> t I-el <br /> ------------ <br /> ----------------------- --- --- ----------------I--- -------------------- <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 Son 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 tha ' the performance of the work For which this permit is issued, I sholl not employ any person in such manner <br /> a rfo <br /> as to b �co e ject to Workman's Compe ion laws of California." <br /> Signed —---- ------------------- ------------ <br /> By -------- -- -------- --- -- ---------- - -------------------- Owner <br /> -------- --- ------------ -- ------0-2k--------- ---- ------- 0-- Title --------efd_y-_�it <br /> (if other than owner) - --V-,- ----------------------------------------- <br /> FOR DEP TMENT SE ONLY <br /> APPLICATION ACCEPTED BY - -- -- -- -------- - ---- - ---------------- ---------------------------------- ---------- DATE 7P <br /> ------------------------------ <br /> BUILDING PERMIT ISSUED -------------------------------------------------------- ------------------------------ - ----------------DATE <br /> ADDITIONAL COMMENTS <br /> ---------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- ---------- ------- <br /> ------- ---------------------------- --------------------------------- ---------------------------------------------------------------------------------------------- -------------- <br /> ------------------------------ -------- --- -------- ----- ---------------------------------------------------------------------- ---------------- <br /> Final Inspection by: ------ -- <br /> --- - ------------------------------------------------------------------ -------------Date ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />