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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 717° ------ Permit No. .-I_�- <br /> (Complete in Triplicate) <br /> This Permit Expires 4 Year From Date Issued <br /> Date Issued -.--__-_---- <br /> -----------------------------------------:--------------- <br /> Application is hereby made to the San Joaquin Local"Health District-for•a-p re mit 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 /> yr <br /> JOB ADDRESS/LOCATION f t - � J` - -------- ----------------------- --CENSUS TRACT -----/ ---�-.----------- <br /> Owner's Name .------ -- - ----------------Ll--- - - -- --- - -- -----------------------------------------------------Phone Ala- 017 -•---- <br /> Address - --------------- - J /l. n` City <br /> Contractor's Name - --------- � = License # �r- Phone '�f <br /> Installation will serve: a ResidenceApartment House❑ Commercial ❑Trailer Court f] <br /> r Motel ❑Other `-----"------------------------ <br /> Number of living units..--/- _ _ Number of bedrooms -_-.Garbage nd --.--------- Lot Size _�--- <br /> x -------------------- <br /> -- ^ <br /> Water Supply: Public System and name ------------------------------------ ----------------- ----------w------------- ---------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'E] Silt(] Clay .❑ °Peat❑ ,Sandy Loam ❑ Clay Loam.[] <br /> r» <br /> Hardpan E] Adobe, Fill Ma.Yterial ------------ If yes, type -----------_--------------- <br /> x ; p <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 per if public sewer is available within 200 feet,) \o <br /> PACKAGE TREATMENT .E_] SEPTIC TANK![.I 'w- 'Size- 1-------------------- '`7 >-- ------ Liquid Depth -----------------_ <br /> Capacity ------------------7-- Type -------------------- Material----------- ---------- No. Compartments ---------------- <br /> Distance to nearest: Well ----------------------Y,'_----------Foundation ----------:----------- Prop. Line .............. <br /> LEACHING LINE [ ] No. of Lines'---:-'`=-------------- Length of each line-----------.---------- ------ Total Length ----------_-------------.--- <br /> iD' Box ------------ Type Filter Material ---------------- ---Depth..Filter Material -----------__------_-..- <br /> -------_-i'-Foundation-----_. - Proper Line ------------- <br /> Distance to nearest: Well -------------- �"� ----------------- Property -----•-•--� <br /> SEEPAGE PIT [ ] Depth Diameter ---------------- Number ---------------------------I Rock Filled Yes ❑ No .�[] <br /> WaterTable Depth ------------------------------------------------Rock Size ----------- -------------------- <br /> r ' <br /> Distance to nearest: Well -----____.-__--_--- _=-_..Foundation .......... ------ Prop. Line --..--_-_--.--.---.--. I <br /> REPAIR/ADDITION(Prev. Sanitation Permit## --------------------------------------------- Date ---------------------------.------I <br /> Septic Tank (Specify Requirements) --------------=---- f} <br /> -X: ---r-�- '_ <br /> --------------- ------- ----r-----------------.-.-- ---------------------- <br /> ---------- <br /> --------------------- <br /> ------------ <br /> Disposal Field (Specify Requirements} ------------ i---- -,------ ---------------------------------- ----------- <br /> --- <br /> ---------- <br /> --- --- ------------- <br /> ---------------------------------------- <br /> ---------------------------------------------------------- <br /> `1 ------------------------ <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 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 /> f <br /> BY ------- - ------------------------------- Title - l ------------------- ---------------------------- <br /> (Ifof a than owner) <br /> ' ` F EPARTMENT USE ONLY <br /> ' L <br /> APPLICATION ACCEPTED BY <br /> DATE �} <br /> BUILDING PERMIT ISSUED ------ ----- -------- -- ---------- .DATE -- <br /> --- <br /> ADDITIONAL COMMENTS ------ -- ----- <br /> -- --_J�.-------------------------------------------------------------------- <br /> ---------------------------------- <br /> ------------ ' �C s <br /> ----------------------------- -- ------------------------------------ -------------------- <br /> � ------- ----- --- --- ---------------- <br /> --------------------------------------- ------- ------------------------------------------------------------------------------------------------------------- - ---------------- <br /> Final Inspection by: ------------------------------------------•------------------------------------ -Date -- _'-- --` � j� <br /> r/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 .. 1-'68 Rev. 5M (/� <br />