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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------ <br /> --------------- - (Complete in Triplicate) Permit No: .!o_ <br /> w �-��- .r.. Date issued <br /> -------------------_--------.-_---------_-_-----___-._-- '"'� This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wok herein. <br /> descricied. This application is made,in compliance with County Ordinance No`•549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI N .-- --- '.- ------- --/Y _1 1--- 4f�� : b 11 ---CENSUS TRACT -------------------------- <br /> I <br /> Owner's Name l i -Phone�3_�.� f . X <br /> --- Lr� ----- �a y <br /> Address [ ------- =-- -----------• City 4°i —.e,-PI-------- --------------- ----------------- <br /> t <br /> Contractor's Name ----- s---- -------------- <br /> License # ---------------------- Phone --------------- <br /> ---- <br /> Installation will serve: Residence Upartment House-[] Commercial ❑Trailer Court ',❑ 4, <br /> Motel ❑Other --------------; <br /> Number of living units:---- Number of bedrooms _Garbage Grinder --------.--- Lot Size ------ _ <br /> Water Supply: Public System and nalme ------------------------------------------------------ ------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet:' Sand'[] Silt❑ Gay ❑ Peat ❑ Sandy Loam 2�--Clay Loam ❑ d <br /> Hardpan ❑ 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,) C~ <br /> PACKAGE TREATMENT [SEPTIC TANK [ J Siie___ _ __ __ __ _._.✓_�7 .__. Li ___ <br /> � � Liquid Depth P_ <br /> ------------ <br /> Capacity - <br /> _-1,1a-o---. Type Materi _c��No. Compartments -----.Y <br /> e­ <br /> Distance �., <br /> to; nearest: Well __6_u -__ f__________Foundation ;f d__--________ Prop. Line _______ _ ______ <br /> LEACHING LINE No. of.Lines ......3--------------- Length;_of each_Line=.___�_Q__�'-----------TTotal Length - . � <br /> r� / <br /> D':$ox .__Type Filter Material (_11'P' Depth� Filter Material-'.--.` -.-,r )7__----------___'.-_....._.. <br /> Distance to nearest: Well _ �__�______.__ Foundation .P_`4______________ Property Line ---__ -- ....._. <br /> � y <br /> SEEPAGE PIT [ ] Depth _____ Diameter _______________ Number _ _______________________ Rock Filled Yes ❑ No 0 y <br /> I - j <br /> Water Table Depth ---------- -------------------------------------Rock Size <br /> I it <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> t ' Irv, , <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------- -;-----_---:---_--,-_: Date -------------------- <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------4-------------:---------------------------------------------- <br /> I + <br /> Disposal Field (Specify Requirements) -----------7---------------------------------------- ---- `--------------------- --------- ----------------- --------------- <br /> - <br /> f, <br /> ! I E °' <br /> ------------------------------ ---=---------------------------------------------------------------------------------------------------lt--- <br /> ------------------- --- - <br /> -------------------- ---------------------------------------------------------------------- ---------------------- ----------------------------------- ---- ------ -=----- k <br /> {Draw existing and required addition on reverse side) 5 1 i <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 Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: r I <br /> "I certify that in the performan'ce of the work for which this permit is-issued, I shall not employ any person in such ma nner4 <br /> as to becon1p subject to Workman's Compensation laws of California." I <br /> Signed , - ---- _ --------------- ----------------- Owner. <br /> BY ---------------- ------------ -� Title y--- ------------------------------ ------------ 1 <br /> r, (If other than owner) <br /> R .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ----------------------------------------- ---------------- DATE '_/�'`� ------k------- <br /> I <br /> BUILDING PERMITENISSUED -------- - --- ---- ---f� -------- ----- ------._----- -----` - --_ DATE - - - - - f <br /> ADDITIONAL COMMENTS _________ _.__ <br /> - ------ -------------------------------------------------------------------- ---------------------------------------------- ------------- -------------1----------------------------------------`------ <br /> ------------------------------------ --- ----- --------------------------------------- <br /> s <br /> -------------------------------------------- - <br /> Inspection b i --- -- - Date - �- ----- --_--- $ <br /> P Y-- ----------- - -- --------------------------- -------------- <br /> Final . . _SAN-JOAQUIN_LOCAL HEALTH. .DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. s •; . '. . . <br />