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jjZ <br /> FOR OFFICE USE: - J I��� ��¢ar�X yfl <br /> � <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- ------------ --------- ----•----- --------------- X02 _ 9�/ <br /> f 1 ! (Complete in Triplicate) Permit No. _ <br /> ---# <br /> Date Issued Date Issued `�.......... <br /> pplication 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 <br /> inn jco,�mppliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI a . - 1-- /---- <br /> -----------------------------------------------CENSUS TRACT <br /> Owner's Name --------------------------------Phone -116 4 7 <br /> - - --------- ----- ---- ---------- -------- --- <br /> Address - 1 ----- <br /> _tRL-R CitY ----`+�- '" ____ -- ------------------------•------ <br /> Contractor's Name ------ -- ----------- ----------------------License # ----------------------- Phone --------------------_--• _ <br /> Installation will serve: Residence;ioKApartment House❑ Commercial [-]Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------- ----------------------------Number of living units:--- ----- Number of bedrooms ______Garbage Grinder -/*fl__ Lot Size /./_i__-.0_ ,_ <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,9 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 /> PACKAGE TREATMENT SEPTIC TANK Size_______ <br /> [ ] - �Q'�--- --- --- --------- Liquid Depth -------------------------- <br /> 6A) Capacity, Typ _ al-- --- o. Compartments <br /> �e�� <br /> Distance to nearest: Well ----.-------------------------------Foundation`__-_-_____-________ Prop. Line -----------/_______-_�(` <br /> .______ Length o ach ine-____-_ __ `\ <br /> LEACHING LINE [ ] No. of Lines __-___ g .----___ Total Length ,:__/ ._._._______ <br /> D' Box _ _ Type Filter Material ,f 'ZDepth Filter Material ______ Q ____-______- r--__--_ <br /> Distance to nearest: Well �J v Foundation ._/ ._________.__ Property Line _ ____ __._____ <br /> � r, <br /> SEEPAGE PIT [ ] Depth' __: ___ Diameter <br /> Number _____---_2---___�_/__- Rock Filled Yes No 0.. <br /> Water Table Depth -------1(!_________________________________Rock Size <br /> Distance to nearest: Well ____./IV----------------------- <br /> Foundation ___ ---------- Prop. Line _�.5 -.--___---_-_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- -------------------------- Date ---------------------------------- <br /> Septic <br /> -_- ____-- -_-___•__-____-__Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------.--------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------- ----------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -•----------------------- <br /> ------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (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 i e performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become ect t Workman's Compensation laws of California." <br /> Signed /; --------------------------------------- Owner <br /> BY --------- ---------------- ------------------------ ------------------------ Title ----------------------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = DATE o �------------------------- <br /> -------------------------------------------- <br /> ILDINGPERMIT ISSUED ----------------- - --- ---------------------------------------------------------------------- --DATE ------------------------------------------- <br /> ToITIONAL COMMENTS ------------------ - --- <br /> - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------ ---- - - ---------------- --------- <br /> --------------------------------------------------------------------------------------------------------------- <br /> - --------------------------------------------- ------------ <br /> Final In ection b z <br /> p Y: ---- ----- ---- -- ---- - ---- ---------------------------------------Date ---1 - ----------------- <br /> SAN JOAQUIN O AL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />