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Qml— <br /> FOR OFFICE USE: ~ ' Y� <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No- - --------------- <br /> (Complete in Triplicate) <br />------ ------------------ -------- <br /> =-- -------------� Date Issued <br />--------------------------------- <br /> This Permit Expires 1 Year From Date issued <br /> a;Application is hereby ade 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. 5A9 and existing Rules-and Regulations: <br /> ,3 O 4• �� Z G(J. ��-- CENSUS TRACT ---------------•••----•--- k <br /> re <br /> JOB ADDRESS/LOCATION-=-._- �="_ --------------------------------- -- - ------------ <br /> ---- -------- <br /> Owner's. <br /> Phone Owner's.Nameff <br /> - -------------------------------------- ------ <br /> s ! /�jyz� --- ---. City <br /> ----------- -- ---------- - <br /> Address/�--- -- - -- §- -----------+_?l----------_-- <br /> f <br /> i s` l e1/ - !417( <br /> Contractor's Name __ -----------------License # ----- :?Phone -- ---•`3----•--- <br /> Installation will serve: Residence ❑Apartment House,❑ Commercial <br /> Trailer Court i0 <br /> Motel ❑ Other ------------------ ------------------ ------ <br /> Number of living units_____________ Number of bedrooms ______-_--Garbage Grinder _____._-__._ Lot Size _________"_____.-_ _ <br /> Water Supply: Public System and name -------------------------------- ------------------------------- <br /> Private <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑— Peat❑ Sandy gLoam ❑ Clay Loam 0 ' <br /> . , Hardpan ❑ Adobe FiII'Material �.`4_ -- If yes,type ---------------------------- <br /> (Pilot <br /> -------------------------(Plat 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 /> ---- Liquid Depth --------------•----- <br /> Capacity --•--- Type --------------- ---- Material------------ ------ No. Compartments -----------------=•-- .. . <br /> Distance to nearest: Well ---- -------------------------------Foundation --------- ------------ Prop. Line ---------..--=-------- . <br /> LEACHING LINT; { ] No. of Lines ------------------------ Length of each fine-------------- ------------- Total Length ------------------------ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material .---------------------------•---------------- <br /> Y <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. -------.----- ---•------ <br /> SEEPAGE PIT [ } Depth -- ---------------- <br /> Diameter ________________ Number _-__._.._j______ .______-"--• Rock Filled yes [] No C3, <br /> Water Table Depth Rock Size __-_--------------------------- <br /> Distance to nearest: Well ------------------------------- <br /> -- ----.Foundation -------------------- Prop. Line ---- ----------­-­- <br /> REPAIR/ADDITION <br /> -�"{ <br /> - Date ----------------------------------1 <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -.�-------------------------------------- <br /> i ---- <br /> Septic Tank (Specify Requirements) ___-----.__- t <br /> A - __ _""-� -------------•_ ---------- <br /> DisposalField (Specify Requirerr)ents) - <br /> ------- ------ -------- ---- - <br /> ------------ --------- <br /> - -- ---- - --- <br /> ., v� . �---------- - � s��' — -------------- <br /> �pc/ __ <br /> rl�i7 _ _ �� F <br /> ___ _ _______________________________________________________________________ __ a7 <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 in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to bec e s "ec t to ork n's Compen 'on laws of California." <br /> Signed <br /> Owner <br /> 9 <br /> i h $/-------------------------- Title <br /> ------------------------------------ - <br /> f By ------------- ----{If------- owned <br /> of er than owner) <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By -'___._ _.____ ---------------- <br /> DATE -----rf------ ------------------- <br /> BUILDING PERMIT ISSUED --------------- <br /> --- ---------- - ----- -- ---------- ----------- ------------------- <br /> ------------°--------------DATE <br /> ADDITIONAL COMMENTS _.-----_-_------------------ ------•---- <br /> ---------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------- <br /> --- -------- ------------------------- ----- - - _ Date <br /> - - - - -- ----------------------------- <br /> -------- <br /> ---------------------------------------------------- <br /> Final Inspection - ---- ------• ----------- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'68 Rev. 5M <br />