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FOR OFFICE USE: t APPLICATION FOR l�SANITATION PERMIT <br /> ---- ---------------------------------- <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires ] Year From Dale Issued <br /> Date Issued ---.-'(-_-�-v <br /> ---------------------------- .. -- ----------------- <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 /> / �'`�' CENSUS TRACT - <br /> S / <br /> JOB AbbRE55/LOCATION ----------- -1--�j-1--9---------- ----r----------- � <br /> Phone.-: 19- <br /> Owner's Name ------27ZA L---------- I,�/ Gam-_ -- - _.`� <br /> , 'r` <br /> Address ------------ � '1 ------ ----------- . City rJ" <br /> Contractor's Name ------- --------- -------License #c '-1' Phone ` _ <br /> r <br /> Installation will serve: Reside nce,'`Apartment House❑ Commercial :❑Trailer Court i❑ <br /> Motel ❑ Other ---- ---------------------------------- <br /> Number of living units:----- Number of bedrooms _ ------Garba � Cf <br /> ge Grinder ' ---- Lot Size __��_--� -- --•••• i <br /> Water Supply ,Public System and name ---- /'�rc -------------------------------------------------Private <br /> 1y <br /> Character of soil to a depth of 3 feet! Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> 'Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type ---_--_-_----------------- <br /> } <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 [ ] SEPTIC TANK'[ � rs Size----------------------------------- ------ Liquid Depth -------------------------- <br /> Capacity ---I---------------- Type -------------------- Material---------------------- No. Compartments ------------•----"- <br /> Distance to nearest: Well ------------------------------------Foundation ----------------------- Prop. Line --------- ------- <br /> LEACHING LINE No. of Lines -----/__------- Length of each line_______ ' g <br /> - Len ----�------ Total Length -----��----•---------- <br /> 'D' Box -AlWY-eType Filter Material _�t ---_Depth Filter.Material -- ---------------------------- <br /> Distance toInearest: Well ---s -------- Foundation -_. --------- Property Line -- --_---_._---_ <br /> SEEPAGE PIT [ ] Depth ......>------------- Diameter ---------------- Number ------------ ------- ------- Rock Filled Yes E] No C1 <br /> WaterTable Depth ------------------------------------------------Rock Size -------- ----------------------- <br /> Distance to)nearest: Well------------------------------------__Founclation -------------------- Prop. Line ---------..-___-..---- <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify <br /> � Requirements ------- --------------------------------------------------------- <br /> -- <br /> Qisposai Field (Specify Requirements) ---- ------- --- ------ -�--'-`- <br /> - ---- b <br /> ---- - ------ - <br /> i -------- <br /> ------------------------------------------•---=------------------------------------------------------------------------------------------- ------ = <br /> I <br /> ---------------------------- ---------- -------------------------------------------------- ------I--------------------------------- -------------- ----------------------- -------------------- <br /> ,J(Draw existing and required addition on reverse side) <br /> I hereby certify that,) have prepared this application and that the work will be done in accordance with San 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 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 Workman's Compensation laws of California." <br /> Signed ---------- -------------- -- ------------------------- j - Owner <br /> BY - c" %L--- J"= -------- Title <br /> (If other than owner) t <br /> FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED BY ---,f�- ------------------ DATE ----.---'-----'7/ <br /> ------------- <br /> BUILDINGPERMIT ISSUED --`-----------------------------------------------------------------------------°-------- DATE . <br /> ADDITIONAL COMMENTS ------------11 - ---------------------- ------------- ----------------------------------------- <br /> ri _ <br /> ------------------------------------- ------------------' --------- --------------------- ------------------------------- ---------- ------- <br /> - -------------------------------------- ----- -•---------------- - --------------------- e..� �� <br /> Final Inspection by: ---------------------------------------------Dat �`�� <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />