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FOR OFFICE USE: <br /> r'vo <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------- -G-x--------��-------- <br /> (Complete in Triplicate) Permit No. <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 ------ r --------------CENSUS TRACT ____________________•____ <br /> Owner's Nam ----/51 -------------------------------------------------------- - _--------------Phone d�7: <br /> Address <�0 -- ��"�7 ------ City -� � ----------------- <br /> Contractor's Name - ---- - ��-fE �J�c�1 _ �_______________License #� L ..3--_ Phone <br /> Installation will serve: Residence�Kpartment House,❑ Commercial:❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units: --/ Number of bedrooms ______Garbage Grinder ------------ Lot Sizec�t-�a ___ <br /> Water Supply: Public System and name ---------------------------------••---------------------------------------------------------------------------Private <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 /> (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 /> er <br /> PACKAGE TREATMENT [ ] w SEPTIC TANK'[ ] Size--------- -------------------- Liquid Depth ------5_. ------------ <br /> -,� <br /> Capacity I'ZaC�_-_,:_-Type <br /> aa-t-- <br /> 7 CCV'No. Compartments -____- _--_.:.._. <br /> Distance to nearest: Well --------- t�-----------------Foundation ----.� ---r___-. Prop. Line ---4-----(-"`... <br /> LEACHING LINENo. of Lines <br /> [ ] ------4?rr►._______-- Length of each Zine-----��------____-- Total Length .---/��----_-_--- <br /> �. �. 'e. <br /> 'D' Box JC., Type Filter Material _ X- /-_Depth Filter Material ------AV------.------------- <br /> Distance to nearest: Well -- 7e------------r Foundation ---_ O____-___ Property Line ______._^_ <br /> r Rock Filled Yes)( No <br /> SEEPAGE PIT [ ] Depth ....... Diameter Diameter -��_____ Number ---.-.-�___-_ - I❑ <br /> Water Table Depth -------- -----------------•..-_-•_---Rock Size �__�X-�� �� <br /> Distance to nearest: Well .-__:;?V0........................Foundation --.C@._--_.-___ Prop. Line :_-_-_..__._._._._ <br /> .... <br /> Nk <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------..-..-. -_._.-----.. --) ' <br /> a <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------- - ---------------------------- <br /> DisposalField (Specify Requirements) ------•-------•------------------------------------------------------------------------------------------------------ ---•----------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------I------------------------ <br /> ----- ------------------ ------------------ --------- - -------- --- - -- ------- - <br /> -- ----------------------------------------------- - --- ------ ---- r--------------- <br /> (Draw existing and required addition on reverse side) 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: �+ <br /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becom ject to W rkma 's Com nsati.on laws of California." <br /> Signed ---- ---- <br /> -- ------ -- -- ------ - -- - - ------ --•- Owner <br /> BY ------------------------ --- - nmac--- '----- --- - - ------ ----- --------- -Title - i <br /> [If other#han owner] <br /> R #RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- <br /> --- --------••---------------------------------- DATE ----- — = - <br /> BUILDING PERMIT ISSUED - --------=--------------DATE -------------•--;-•-••--------------------- <br /> ADDITIONALCOMMENTS - - -- -- -------- ---- - ------ - ----- --- ------------------------------------------------------------------------------------------------------------ <br /> °2� � C ----------------- ------ ------ - - ----------------------------------------------------------------------- <br /> ----------------------------------------- <br /> -------------------------------------------------------------------------------------- ----------------- <br /> Final Inspection b __-_Date09 <br /> SAN JOAQUIN LOCM HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M , <br />