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L <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> '----- ----- ---------- --- <br /> Permit No: <br />{ (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued . -:_ '7� <br /> ----- <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> I described. This application is made in compliance with County Ordinance "55499d existing Rules and Regulations.IA <br /> JOB ADDRESS/LO.CATION- _�� =,= -Ic[ -4 �� •--.-1-L----- -- - CENSUS TRACT ----------- -- ------ <br /> 4 <br /> Owner's Name -- 0-'"` `------------------------------- ------------- •-------------------P e - - ------ ---_-•- •--------- <br /> �, � <br /> Address e-' ( City -�rlf� e <br /> ---- <br /> Contractor's Name ---------------------------------------/Apartment <br /> -------------------------------z------.License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence House❑ Commercial Trailer Court ,❑ <br /> iMotel ❑Other _=-__-_ _-: ----------M------ - <br /> i+ <br /> Lot Size ----------------- ----------------------- <br /> :��� l <br /> i Supply: Publicliving <br /> y I --- ., -- •---,. ---9_� ��-;..--,�--.-.---------------------------;---Private ... <br /> Water Suof Publ clSsstem and�.namer-of---e--rooms-__---------Gar a_ a Grinder ------ -•'��x^�� <br /> "Character of soil fo a depth of 3 feet` Sandlt❑ Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam ❑ <br /> [ I <br /> Hardpan ❑ Adobe ❑ Fill Materibi ----------- if yes,type----------------------- -- <br /> f (Plotplan, showing size of .l ot; Iodation;of system in relation to well`s, buildings, .etc. must be placed on reverse side.) <br /> k NEW INSTALLATION: (No septics tank or seepage pit permitted if public sewer s availabl within 200 feet,] <br /> . k <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-----------------------------.------------------- Liquid Depth .-__________--_--_-_--.-_. <br /> k4dpacity .-- -_ -_�=--- Type - ------E i----- AGferi�I----------- ---------- No. Compartments <br /> t• �J 1 <br /> Distance to nebrest: Well -------------------------1--------i-Foundation ------- ------------- Prop. Line --------------- <br /> . <br /> iLEACHING LINE [ No, of Lines ----------------- - ---- Length of each line_--._---_-_-_______._._/- Total Length <br /> 'D' Box -- --------- Type Filter Material ---------I--------1-Depth 'Filter Material ------------------------------------------•_ T <br /> I - <br /> Distance to nearest: Well ------------------------ Foundation .-_--_--------=-----__- Property Line -----------------_----- <br /> SEEPAGE <br /> -__ _ __ -SEEPAGE PIT `[ ) -._�. Depth ---- --------------- ---------------- Number ---------------------------- Rock Filled Yes ❑ No iC <br /> Water Table Depth :-------------� .-- ._Rock Size-------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation PermitI -------------------------------------------- Date <br /> tI <br /> --------- <br /> nts) _____ ---- iiW -- ------- <br /> Septic Tank {Specify Requireme <br /> ___ C� ...... <br /> Disposal Field (Specify Requirements) ---____________ _ _ _ ____,_-_-_______ _ _ <br /> - ----- -------- - -------------- <br /> ------- -- ---- --------------------- _-_-___---.--------- ----_. l v- _ _..__ _.__. <br /> _____ ___ __ __ ______ ____ Y L'X <br /> .[[ ---------------------------------------} ---------------------------- <br /> (Draw <br /> ----- '_---.----------.-- <br /> ---------------------------------------------------------I----------------_---_-.._-----_-------------______,_____-__-_-_y----__--____! <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, inaccordance�with San Joaquin <br /> County Ordinances, State Laws,'and Rules and Regulations of the San Joaquin Local Health�DistretaHome owner or licen• <br /> sed agents signature certifies the following: I <br /> "1 certify th the performs a thedworkor which this permit is issued, I shall not employ any person in such manner <br /> as to bec e s bect to rk Coion laws of California." r <br /> Signed __ _. _ Owner <br /> By ---- ---- - --------------------------- -------- ---- ---------- ---------------------------------- Title --------- .-------------------- ---------------------------------- <br /> (if other than owner) I <br /> FOR .DEPARTMENT USE-ONLY <br /> i <br /> APPLICATION ACCEPTED BY - - ------ : 1 '------------------------------------------------------------------ DATE-•- ---7 ----------- <br /> BUILDING PERMIT ISSUED''- i ---- ` ) �—A-------------------------- -------DATE ------ -------------------- <br /> ADDITIONAL COMMENTS ------ --- •-•---------------- ------------------------------------------------------ -------------- . <br /> ----------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- <br /> ------------ -------------------------------- - --- ------------------------------------------------ ---- ------------------------------------------------------------------- ---------------- <br /> -------------------------------------------- - -----------p- ---_------- <br />° Final Inspection by- -------------- --------- ---=_ti---------------------------------------- ------------------ Date ----- / -------- - <br /> j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'68 Rev. 5M �f <br />