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FOR OFFICE USE: , w <br /> 1- <br /> A;�. APPLICATION FOR SANITATION PERMIT <br /> r� ,.. ._ <br /> e' Permit No. __ _3-_5.$ <br /> _ 3 ,(Complete in Tr�plieate} � -- ---- <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 /> c <br /> JOB ADbRESS/LOCA//ThON�� IQ - -- ----------- --- X------------ -------------:----CENSUS TRACT ---------------•---------- <br />' Owner's Name ._.SrC /__ ---- - - ----- --------- ----------F--------------------;: -----------------Phone <br /> Address _-� <br /> n <br /> f ~- <br /> Contractor's Name / -r� ----- ---- - `- ---------- --- .License # �t�� 8' -- Phone ------------------------ <br /> Installation will serve: Residence Apartment HouqE01ommercial :❑Trailer Court ,❑ <br /> Motel ❑Other __- _---______________ <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> Water <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 ❑ <br /> IHardpan 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 permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ JP SEPTIC <br /> TANK0 Size�_x2Q.__rr _ ______ ______ Liquid Depth 7�__________-_________ *J <br /> Ca acit �C� _�__ Type �____ MafierialNo. Compartments ____43•_______:___. r` <br /> Distance to nearest: Well ______�__`�.� ,r' { <br /> .---____--Foundation ------/© -- Prop. Line ---- - •__- <br /> �.7 V <br /> LEACHING LINE [ No, of Lines ____ --- _?- _ Length of each line--__-_ <br /> r� - - -�-b-+!i- ---- Total Length :-�.t1.o: � 1 <br /> 'D' Box -----/_-___ Type Filter Material k_ ______F..nd.tion <br /> __1_k_ ____Depth Filt Material ------141_'._____-------________________ U a <br /> Distance to nearest: Well ------!__Sd_ -------- _4_ __-__ Property Line S <br /> i <br /> SEEPAGE-PIT - _ __.- Rock;Filled-�Yes� =No-j---- NumberDepth Diameter- � = <br /> " <br /> Water Table Depth ------------- ----- - ---- --------,--------Rock Size __A� - - -3 ___--- ,_ <br /> Distance to nearest: Well .___ _ G! _._Foundation __ !_ ________ Prop. Line ____--- '� I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------:------------- Date ---------------------------------- <br /> Septic <br /> ------------------- _--------Septic Tank (Specify Requirements) -----------'s----------------------------------------------------------------------------------------------- • p� <br /> Disposal Field (Specify Requirements) ___________ E <br /> ---------------------------------•--------------------- I <br /> --------------------------------- -- ------------------- -----------------------------=-------------------------------------------------------------------------------------------- <br /> 'l(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 San Joaquin j <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 subject to Wm s ompensationjows of California." <br /> d <br /> Signed ------------------------- Owner ,.. <br /> :----- - ---- - -------------- <br /> BY ------------------------ ----- -- - ------------------ Title l - H <br /> ---------------- <br /> (If other tha caner) , x <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -- ------ ------ ----- - ---------------- --------------------------------- . DATE <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ------------------------ ------------------------------------------------------------------------------------------ = <br /> ------------ ----------------------- --- ------------------ ---- --------- ---------------------------------------------------------------------------- tv <br /> Final Inspection by: _ -- - :------- --------------- ---------------------- ---------Date ---- ----T''--I--- - - ---------- <br /> AN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev, 5M <br />