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FOR OFFICE USI: APPLICATION FOR SANITATION jPIERMIT <br /> Permit No. ---- ----- --- ---- � <br /> --------•---------------- <br /> ------------------------- - - {Complete in Triplicate) / <br /> - --------------------- <br /> ----------- <br /> Date Issued -.- ----�1--.�� <br /> ------ ---------- - <br /> This Permit Expires 1 Year From Date Issued <br /> tiinstall the <br /> Application is hereby made to the San Joaquin <br /> Local <br /> HlthDiOdnana No. 549 and existing Rulesand Regulat ons-. <br /> described.,This,appiication.is madeom compliance h <br /> --------1` -t- -„'”--� ---------------- ---- -- <br /> ------ =------ --------CENSUS TRACT ----------------1---•----- <br /> JOB ADDRESS/LOCATION ------------ Phone ------------------------------- <br /> Owner's Named_-):,.r5;-- _lf --- ------1-- ---------- -- r� <br /> of ,{/ �h� - Cit -------------"-------- --------------_--- <br /> ! ------ -- ---------------- Y <br /> Address "-.8"�-Q-'- ---�''°- <br /> �/i'l� --- -------- - -- - - ----- ----License # --------:------ ------- Phone ------------------------------ <br /> Contractor's Name ---------- -----------" <br /> --- ----- ------------------- <br /> JD <br /> Installation will serve. <br /> Residence Apartment House <br /> Commercial:❑Trailer Court <br /> r <br /> Motel [--I Other -------------------------------------------- <br /> Number of living units:----/----- Number of bedrooms ---�--..Garbag Grinder -N --- Lot Size -------------------------------------- <br /> -----Private <br /> --•-------•----- <br /> ❑ <br /> -•^ f .�'!� �'+ Ate <br /> - -------------- <br /> Water Supply: Public System and name --- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay F-1Peat ElCia Sandy Loam y Loam ❑ <br /> Hardpan F1Adobe E] Fill Material ------------ If yes,type -- <br /> showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.j <br /> (Plot plan, sh g i <br /> �t ermined if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: (No septic tank or seepage p' p <br /> i lx------ ----- - <br /> -- - Liquid Depthth . ��'----------- <br /> i PACKAGE TREATMENT SEPTIC TANK:� Size--_ 2h' ments .._ ------ <br /> Capacity Type -_ Material-- -- V_4 Na. Comport 1-4 <br /> - ---- Prop' Line -- <br /> Distance to nearest: Well ------------------------------------Foundation -- II <br /> a,3- ---__---- Length of each line----- -- ---- Total Length :-�- --------- ---------- <br /> LEACHING LINE K No. of Lines _ t i <br /> - -_QC. --.Depth Filter Material __- l <br /> 'D' Box -----�_-- Type Filter Material - _0-__^ ------_- Property Line <br /> � - .--_ <br /> Distance to nearest: Well --- ""_w--__"_-_"--_ -- Foundation ---- = <br /> P11*°, ] Depth <br /> - Diameter (a-_- Number ___------ _ Rock Filled Yes X No C <br /> I <br /> (3) s�M � Water Table Depth -------------------- Rock Size -------------------------------- <br /> Distance to nearest: We ----------------------------------------- (/} <br /> ------- -- <br /> -------- -Foundation -------------------- Prop. Line __------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---- RA� <br /> i <br /> ' ------ -------- Date ----------------------------------) <br /> ---------------------- <br /> ---------------- <br /> --- --------------- -------- <br /> Septic Tank (Specify Requirements - •, <br /> Disposal Field (Specify Requirements) ------------- "---"-------------- <br /> ----------------------------------------------------- <br /> iw ------------- <br /> ' ---------- - - <br /> ---------- ----------------------- <br /> ------------ <br /> (Draw existing and required addition on reverse si d e <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 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 -- ---- -------- ------------------------ <br /> ----- <br /> ----------------------- Owner <br /> Title ------------------------------------------------------------------------ <br /> ------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE -- -s ------------------------- <br /> APPLICATION ACCEPTE=D BY 5.9.x.-- = - DATE --------------------------- <br /> = ----------- <br /> BUILDING PERMIT ISSUED ---------------------"-------- -----•----------- <br /> ADDITIONAL COMMENTS ------------------- --------------- <br /> --------------------------------------- <br /> _.-----"---------------------------------------""---------------- ------------"---------"-------- -------------------------------------------------- <br /> ----------------------�---- -- - ----- <br /> -------------"--------------_-----__"--__----- _ -- --------- <br /> - <br /> ---- _ <br /> ------------------------------------ - r ___- __--.__--._-._ <br /> Final Inspection b l� = - <br /> Date <br /> -- ----- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F H 9 1-'68 Rev. 5M. <br />