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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ....... Permit No. <br /> f*_ (Complete in Triplicate) <br /> -----------------------------0" <br /> -------- ------------------0r",50 <br /> This Permit Expires 1 Year From Date Issued Date Issued --5--*---: <br /> ---------------------------- -------------------- _ <br /> Application is hereby made 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 unty Ordinance Na. 549 a d existing Rules'dnd Regulations: <br /> JOB ADDRESS/LOCATION <br /> �' ) 51--.�!_ -- - --------- '� - -- ---- ------CENSUS TRACT -- ----------------------- <br /> Owner's Name ----- "'--L•�C/-F-- --1----- - - --- --- Phone � r'1-.---- <br /> Address ------------------------------3--� - ------r-- ------ <br /> 4f <br /> --------------- <br /> -. City Q <br /> Contractor's Name ----------------------- ----- ---= -------------- - --- I ---License # -------- ----------------- Phone <br /> Installation will serve: Residence ❑Apartment House❑ Commercial[ Trailer Court i❑ <br /> Motel Othe_r ------------------------------------------- <br /> Number of living units:----/----- Number of b4drooms�-- -----Garbage Grinder -------- '. Lot Size ---- --------------S- -_- <br /> Water Supply: Public System and name -------------------- -- ---- -------------------------------------------------------------------------------Privatex <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑n Clay Peat ElSand; Loam -❑ NCllay Loam 0 - <br /> Hardpan EJAdobeX'-\Fill Material ------------ If yes,type --_-_----- <br /> 1--------- --- - <br /> (Plot plan, showing size of lot, location of system in relation to-wells, buildings, etc. must be placed on reverse side.) W <br /> I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK_[_] Size------------�t -------------------------------- Liquid Depth _------------------------- IZ� <br /> Capacity ----- ------------- Type -------------------- Materia ------------------- No. Compartments -----------------=---- <br /> Distance to nearest. Well -----------------------------[-----Foundation ------------------ Prop. Line ------•--------------- <br /> ---------------------- Length of each [line-------- ------- Total Length -------------- <br /> LEACHING LINE [ ] No. of Lines- g g <br /> 'D' Box ----F=------ Type.Filter Ma,�Iteerrial -------------�-----Depth FilferlMaterial -------------------.-------------_---------- <br /> Distance to nearest:-4ell --_- -------_ Foundation""_'_'--`__-- ---_-, --- Property Line <br /> ------------------------ <br /> SEEPAGE PIT [ ) Depth - - - _ -- ~L <br /> - - _ - Diameter ---------------- Number _______._.-.---------- Rock Filled Yes ❑ No i❑ <br /> Waterable �Depth ------------------------------------------ -----Rock Size ----------- \--------- d <br /> Distance to nearest: Well ---------------------------------- -_-__Foundation - Nm�,- .Prop. Line ��_.._____-__-__-__ <br /> REPAIR/ADDITION(Prev. Sanitation PJrmit# -----------------------------------------L Date ----------------- <br /> Septic <br /> - _---------__-Septic Tank (Specify Requirements) -------- --------------------- ----------------- --------------------- <br /> ----- - - ------ <br /> - r <br /> ----------------------- <br /> Disposal Field (Specify Req irements) ` . - ------------- <br /> tF F �'r` - --- -- - --- ----- --------- <br /> ,_ __ - <br /> --- ----- - ------- - <br /> ----------------------- ------ t_ --------- ��---- --- -------------- ---------------- -------------------------------------------- <br /> "IN&OPaw exi existing and requi d additi Pn on reverse sidel <br /> n:, <br /> I hereby certify that I have prepared is application and thh'dt-Ithe4 work will be done in,aecordance with San Joaquin <br /> County Ordinances, State Laws, and Rules'�and. Regulations '60--the, n Joaquin Locaf'i�alth District. Home owner or 1i40.J.,� <br /> sed agents signature certifies the following: �`r <br /> "I certify that in the performance of the wor�2 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 ' ------------------------- Title ---- ' <br /> (If other th owned ' <br /> FOR DEPARTMENT IJSE I ONLY <br /> APPLICATION ACC PTED BY --------------------------------I---------------------- DATE t ' ------------------------,. <br /> BUILDING PERMIT ISSUED ----------------- - ----------------- •------ f----------------------L f-------DATE ----- ----------------------------- ------- <br /> ADDITIONALCOMMENTS --------- --------------------------- --------------------------------- ------- ------------------ ---------------------------------- <br /> I <br /> ------------------------------------------------------------------------------------------------------------ --- -- - --- --- -- <br /> ---- ---------------- ------- ------ ------ -• ----- <br /> Final Inspection by: - �� Date -----'� �l <br /> - -- - --- -- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ii <br /> E. H. 9 1-'68 Rev. 5M <br />