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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------ (Complete in Triplicate) Permit No. .-__.�` <br /> ------------------------------------------------------ -- <br /> --------------- This Permit Expires ] Year From Date Issued Date Issued -/_.---� ----7� <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 'arid existing Rules and Regulations: <br /> T6 s_ <br /> JOB ADDRESS/LOCATION -------� ---- ------ - ---------- -------- --------r----------------- F�1SUS TRACT <br /> Owner's Name ----- r / *�-- ---- ------- ------------------- <br /> Address <br /> -------------- • Phone 3A 6 <br /> Address {� ------- - - -------- ---- - ----------- city <br /> ' ---------- ----- ---.License #�'G //___-- Phone <br /> Installation will serve: k ResidInce D<Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel F-1 Other ------------------------------------------- � _ � <br /> Number of living units:---.�_--�.- Number of bedrooms __5----- Grinder --------. Lot Size _ Z_ _ _TS ......... <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------PrivateX <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 --- r-.--------------------- , <br /> {Plot pian, showing-.size of lot,, location of system in relation .tawrvells, buildings,-etc. .must-be placed on reverse side.] <br /> i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if p.ublic sewer is available within 200 feet,) 61 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK j ] Size---------- ---------- ------------------------- Liquid Depth ------------------------. r <br /> Capacity -------------------- Type -------------------- Material-----r-- - No. Compartments ------------------•--- <br /> Distance to nearest: Well ------------------------------------Foundation -_-- Prop. Line _--_---_---_---_.-_- <br /> LEACHING LINE �[ ] No of Lines ____-.----.--_----_--_ Length of each line---- _----_-----_ _ Total Length <br /> _ ----------- --------•-----_ <br /> 'D'. Box ------------- Type Filter Material ------------------.Depth Filter Material ------------------------------------.------- <br /> Distance to nearest: Well ------------------------ Foundation'_'"-"-'__-- _-_ :` Property Line -_-----------_--._.----- <br /> SEEPAGE PIT [ ] Depth ---- .-__._Diameter_ -----------------,Number ---------------------------- stock Filled Yes ❑ No i❑ <br /> Water Table Dept --------- --------------------------------f_-Rock Size ----------------------- <br /> Distance to nearest: Well ---------------------------------- -----Foundation -------------------- Prop. Line ---------------------- <br /> t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} <br /> Septic Tank (Specify Requirements) = ` ,/ ,-�J—` <br /> Disposal Field (Specify Requirements) ------------- __-- ___-- -- --------- ------zIv---- <br /> -- -- ------------------' `'` ,---- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> I <br /> - ---- ---- - <br /> (Waw existing and required addition on reverse sidey' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rulesrand.Regulotions.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 ---- ------- Owner <br /> --------------------------- <br /> Ir <br /> By --r-- ' -------------------- Title ------- <br /> - ------------------------------------------------- <br /> (If other t owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.--- <br /> -,\,k <br /> - -- - DATE ---Z-�--AQ- ---------------- <br /> BUILDING PERMIT ISSUED ---------- Lmtt ---- DATE <br /> ----------------- <br /> --------------------- --------------------- ---------------------------------------- <br /> ADDITIONAL COMMENTS ------- -------------- -- -- ------- ---- ---- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------T--------------------------------------- ----------------------------------------------------------------------------------------- <br /> --------------- --------------- # <br /> -- - ------- - - <br /> Final Inspection by: ----------- _ -- ----------------------------- -- -- -------Date ----- _T.3_/_.-nG�------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />