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w: FOR OFFICE USE: i <br /> APPLICATION FOR SANITATION PERMIT <br /> -- ---- - ------- ---------------- Permit No. <br /> (Complete in Triplicate) 5 <br /> ---------------------------------------------------------- <br /> Date issued 1.2--.1_3-:-�7 J <br /> ---------------------"------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 . ------ --------7 --------- p ----------------------CENSUS TRACT --•-------------- -------- <br /> Owner's Name om - ---- Y ----------------------------------------Phone --------------------- <br /> Address �f�'-- r ------- ,---- ' `�` ---- City ---------------'v-------------------------------------•--------------------- <br /> Contractor's Name --- <br /> -------c -e-ss1------ --------License # Phone ------------------=--•---• --- <br /> Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court !,❑ <br /> Motel ❑ Other - ------------------------------------------ <br /> Number of living units:------ --- Number of bedrooms -- ---Garbage Grinder ------------ Lot Size ---- <br /> Water Supply: Public System and name ----------------------•------ --•------------------------------------- ---------------------------------------Private ❑off <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 /> i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) f <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size-------------------------------------- --------- Liquid Depth -----------------------.-- <br /> Capacity. -=---------------- -- Type ----- -----=-------- Material---------------------- No. Compartments ----------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------_--....__ (y/� <br /> LEACHING LINE [ J 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 -------------------- Diameter 3e--------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> - r Water Table Depth -----`------------------------------Rock Size -------------------------------- <br /> --------------------------Foundation <br /> -------------------------------------------Foundation -------------------- Prop. Line -------.-------- <br /> REPAIRJADDITION(Prev. Sanitation Permit# ------------------ ------------------------- Date ------.---.----------------.------) <br /> Septic Tank (Specify Requirements] -- _----------------- -------------------------------------------------------------------- ­------------- --------- <br /> Dis 1 Field (Specify Requirements) "--- - <br /> _ �__ '�-e- +-. /��—�---- sT�-•--------------- <br /> � b ,�C'-C ' _[` - �^•-� tea- —r_,f..------ ------(-P b------ -- - - - <br /> -�`- ` - --------- ------------------- <br /> YI (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 <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 or which this.permit is issued, I-shall not employ any person in such manner <br /> as to became subject to Workman'XCom ensaltion laws of California."-Signed -------------------------------------------- ------ .--- -- -- -----. Owner <br /> BY ----------- --------------------------------- ------------ -- ------ Title - ------------- <br /> ---------------------(If other than owner) J 1 . <br /> FOR DEPARTMENT USE ONLY- ----- — — <br /> �-�- <br /> APPLICATION ACCEPTED BY .. - --- -- --------------------------------------------- DATE - .-------� �--------- <br /> BUILDING PERMIT ISSUED - _ t '= DATE <br /> - - ----= ,' <br /> ADDITIONAL COMMENTS ------------------------------------------------�,- --=---'- -------------------------- <br /> --------- -----------------=---------------------------------- - - ---- ---- ------------------------------------------ ---- <br /> ------------------------------------------ ------------------ ---------------------------------------------- -------------- -------------- <br /> ----- <br /> ------------- <br /> Final Inspection by: ---- -- ------------Dat e,/„ --- -------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E- H. 9 1-'68 Rev- 5M <br />