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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _., <br /> ________________________ This Permit Expires ] 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 :------ T/r`f---57�--------- ---------- ---- ---------------- -----CENSUS TRACT ------------- <br /> Owner's Name ---- X� --(!r---------- ---------- ------ -------------------Phone <br /> Address ---- ---- ----------------- ---------- ------------------------------------------------- City -------------------------- "----------------••------ <br /> ContractorQ-,Name --� �$-------<eeel-47`1e------- ------------------------License # Phone <br /> Installation will serve: r Residence'[-]Apartment House�❑ Commerci <br /> a0vyrailer Court i❑ e <br /> Motel ❑ Other --------------------------------------- <br /> Number of living units:_.-------- Number of bedrooms -------~_Garbage Grinder __-_:__ Lot Size <br /> Water Supply: Public System and name ------------------------------------------------------------ -----------._.------------- ------------------ Private�] <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam T Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ___I______ If yes, type ---------------------------- <br /> (Plot <br /> _________._________-- --(Plot plan, showing size of lot, location of system in relation to, wells, buildings, etc. must be placed on reverse .sideJ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet, <br /> PACKAGE TREATMENT [ I SEPTIC TANK Size ------------------- Liquid Depth __;001 - <br /> Capacity Type Material ,6` Compartments <br /> Distance to nearest: Well ------}---®_`-----------------Foundation _./ ------------ Prop. Line _ �__._........ 0 <br /> LEACHING LINE No. of Lines l _____-____ Length of each line_._-___ r <br /> 9 -------- Total Length . 0 <br /> 'D' Box &W_ Type Filter Material _-- _ Depth .Filter Material __1_ ----_____________________________ <br /> Distance to nearest: Well ---------------- '%y' Foundation _:. _--------.-_ ------- Property line -- <br /> _SEEPAGE PIT [ ] r _ Depth --------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth _____Rock Size __________________--____-__ <br /> Distance to nearest: Well --------------------------------------- Foundation __._. ------------- Prop. Line --'__.________.__..... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -.-------------------------------•r- --. Date ------------f----.----------j f <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------- --------------- = = <br /> ! u <br /> Disposal Field (Specify Requirements) ---------------- -- ---------- ------------------------ -------------------------- - --------------------i-------•--------- - <br /> a <br /> ---------- --------------------- ----- <br /> - -------- --------------------- <br /> ------------------------- I <br /> (Draw existing and required addition on reverse side) ! y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin t <br /> County Ordinances, State Laws, and Rales 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 ------------- ------ ------------------------------------------------------------ Owner <br /> By -------- ---- ----- --------------------------------------- <br /> --------------------- <br /> ------------- Title ---- ----------------- <br /> - <br /> (If other than owner <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------- - -------- ------------- - ----- -- - ---- - - � DATE ---- ------------------- <br /> BUILDINGPERMIT ISSUED --------------------------------------------------- ------ ------------ -- ---- - -- --- --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------ ---------------------------------------------------- <br /> -------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ' <br /> ---------------------------------------------------------------- ------------------------------------ ---------------------- -------------------------------- ----- ---------- <br /> ------ <br /> Final Inspection by- ---------------------------------------------------------------------------------------- ---- ------Date ---�1- G?-�---- ---------- <br /> SAN JOAQUIN LOCAL HEALTH f RIOT , <br /> E. H. 9 1-'68 Rev. 5M l <br />