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FOR OFFICE USE: . <br /> APPLICATION FOR SANITATION PERMIT Permit No- -----7-S.-_7 -�,� <br /> ---------------------------------------- --------- <br /> --------- ----- <br /> (Complete in Triplicate) _ <br /> ------------ ----------------------------- - a " <br /> Date Issued __ --- --'-. <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein J <br /> described. This application is made in •co• pliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> Q/ p S- sL_ <br /> E1 _-[-:/_A tR6J � :�_.-. .CENSUS TRACT - <br /> JOB ADDRESS/LOCATION - p0 ----- ----- --- -- - <br /> Owner's Name ----------------------� ..... (_ - '------------------------------------------ - Phone <br /> ------------------------------------------------ ---•--- <br /> Address -------------------------- .------------------------------------------------=------------------ - City <br /> CAXSEContractor's Name -.------- ---------------------------------------------------------------License # ---------:-------------- Phone ------------------------------- <br /> Installation <br /> ---=---------- ----Installation will serve: Residence 0 Apartment House-El Commercial:❑Trailer Court l❑ f <br /> Motel ❑ Other -------------------------------------------- A <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 E] Peat E] Sandy Loam lay Loam:❑ <br /> Hardpan F-1Adobe•[ Fill Materia! - _ 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 seepa it permitted if pyblic sewer is available within 200 feet,) <br /> [ ] C ANKH . Size---- ( --��{=---j----------------------- Liquid Depth .. . <br /> PACKAGE TREATMENT SEPTI <br /> Capacity - - - _____ Type _11 Material6:1'1-rI'rA1—' __-. No. Compartments ..... :............ i <br /> Distance to nearest: Well ----_ -------------___-----.Foundation -__� -_-.......... Prop. Line ---. a..:.._----- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------------.----------- N <br /> 'D' Box ..---------- Te Filter Material ----Depth Filter Material -------------------- _ 4 <br /> LTER Distance to nearest: Well ----------------------- Foundation -.-----_------_-------- Property Line ----���--_-.--.-.--- <br /> SEEPAGE PIT [ ] Depth ----- ----------- 6iameter _-_--- N Her ____-�-X-5d- Rock Filled Yes [] No [ j <br /> WaterTable Depth --------------------------------------------- ---Rock Size -------------------------------- 1 <br /> Distance to nearest: ----------- <br /> - <br /> Well --------------------------- - Foundation -------------------- Prop. Line ----------......--..-- <br /> k <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------- --------- Date ---,--------.-.-------------------) <br /> SepticTank (Specify Requirements) -----------------------------------------------------------=----------------------I-------------------- -------.----------------------------- <br /> Disposal Field (Specify Requirements) ------------- ----------------------------------------------------------------------------------- --------------- <br /> J <br /> ------------------------- -------------------- -------- -- <br /> ---------------------------------------------------------------------- ------------- ------------------------ <br /> I �_-. r�_ - <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 ---------j-------------- --------------------------------------------------------- Owner <br /> 'k By � J k '''� Title --------------- ------------------------------ <br /> (If other,,tfian owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. � '©----------------------------------------------------- -- DATE <br /> BUILDING PERMIT ISSUED ------------- -------------DATE --------------10------------------ ------ <br /> ------------------------------------- <br /> ADDITIONAL COMMENTS --- -- -- -- --------------------------- -----------------------------------------------------;`-=-------------------- <br /> ---------------------------- <br /> ------ ---------------------------------------------------------- -?-----------------------= <br /> ----------------------------------.-- --------- - -------------------- <br /> --------- --- - ---- -- - --- - -- --------- -- --- Date -- - - =-- <br /> Final Inspection ate ------ ----��J`�---�� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E.'H. 9 1-'68 Rev. 5M -- <br />