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FOR OFFICE USE: <br /> APPLICATION.,FOR.SANITATION PERMIT 7�r3y3 <br /> ------------------------------------ ------------ - <br /> (Complete in Triplicate) Permit No. <br /> --------------------------------------------------------- <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 /> JOB ADDRESS/LOCATION - __ _______ __! _, _- --------CENSUS TRACT ----------------- ------- <br /> 6# <br /> Owner's Name ------------- ----- �------ <br /> ii -------------------------------------------� ---- �- - --Phone �---- <br /> ----- --- -- --------------- <br /> Address --------------------------- a-'-'---------------------------------------•--. City <br /> Contractor's Name ----------- - '-1-- ----------------------------License Phone <br /> Installation will serve: Residence ❑Apartment House-[] Commercial Xtrailer Court ;❑ <br /> Motel ❑Other --- ------------------------ ------------ <br /> Number of living units:------------ Number of bedrooms ____________Garbage Grinder ___________ Lot Size _________ — ?QJ____________ <br /> WaterSupply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: <Sand' � Silt❑� Clay,E]-❑- Peat❑� Sand Loam ❑ GaY Loam OV5 <br /> Hardpan - <br /> ❑ 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,l <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size----------------------------------- ------------ 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 -----__-_______- ___.--� _....:.._..-. <br /> Distance to nearest: Well ------------------------ Foundation ---------------------.-- Property Line ------------------------ <br /> SEEPAGE PIT Depth -----AD--------- Diameter __1-�-&-_�__ Number .______-y__________ Rock Filled Yes No ❑ + <br /> C2l Water Table Depth ------------------------------------------------Rock Size --��.----����----- <br /> i <br /> Distance to nearest: Well ----------------------------------------Foundation77----- Prop. Line _.�---------____-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Dat-e ----------------------------------) k <br /> ,. <br /> Septic Tank (Specify Requirements) - - -------------- ----- -- - -----------------------------------------------------.--------------------------- <br /> �`''•__ � 1 <br /> Disposal Field {Specify Requirements) ---- --- <br /> -` -- �2,r___ -•cf _ <br /> • of ✓.-� _ y <br /> 1 <br /> ------------------------------------ ____ ___ <br /> (Draw existing and required addition on reverse side) <br /> =I,hereby.certify that;l�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.ce rifles the followings <br /> "I certify that in the pert rinpnce 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 Compen3ation laws of California." I <br /> tr-.. .i <br /> Signed - Owner <br /> BY �` ----- ------ Title ----------- =------- <br /> -- -- ----------- Title <br /> oche t an owner) <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .____-- - ---------------------------- DATE -- <br /> BUILDING PERMIT ISSUED ---- ----- ' " -- DATE -------------•- <br /> ADDIT ONAL COMMS T -� rc.crp�ci ---- (�-p - - 'tQ-- -- - - <br /> -----4TW-------------------------G(�!►lL. -------------------------------------------- -------- ----_---------------- - -- ----------- <br /> - R ---- <br /> ----- ---------- - ------------------------------------------------------------------------------------------- -- -•------ - <br /> Inspection b _-_Date <br /> Final Ins __ - <br /> P Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />