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Al <br /> FOR OFFICE USE: / <br /> `r <br /> APPLICATION FSR SANITATION PERMIT <br /> - --------------/ 7 ----------------- �.FS 2. <br /> lz <br /> Permit No. -..- _ _ <br /> {Complete in Triplicate} /r <br /> --------------------------------------------_____________ This Permit Expires I 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_ _ _--- -------------CENSUS TRACT -------------------------- <br /> Owner's Name -- _ -----/--------------------- ---------------- ---- --Phone <br /> Address <br /> _ - City ... <br /> Contractor's Name ------— ---------------License Phone <br /> Installation will serve: Residence Apartment House-[71 Commercial :E--]Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:._ _-- Number of bedrooms _7------Garbage Grinder - ---- ----- Lot Size -_______________'_ <br /> Water Supply: Public System and name ----- -- t �� -----------------------------------...............................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AclobeX Fill Material ------------ 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 seepage pit permitted if public sewer is available within 200 feet,) ' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ____________---__,.._._ 1 <br /> Capacity -------------------- Type ---.- -------------- Material---------------------- No. Compartments ----------- ...... <br /> �i Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------•-------------- e , <br /> LEACHING LINE { ] No. of Lines ______f______________ Length of each line-- --------------- Total Length ---GQ__0_________.._-__ <br /> 40X fS��Jcj 'D' Box 6:✓___ Type Filter Material --- Depth Filter Material ------ ` <br /> Distance to nearest: Well __ tr.Z1 ------- Foundation _/0----------------- Property Line _.�--------.------- <br /> Z4 11fU RGT Depth f0------------ D+e � <br /> - ------- Number-------`---------- ---__ Rock Filled Yes �o 1❑ <br /> Water Table Depth -------- -----------------------------Rock Size -__2 z X-•----Z----- <br /> Distance to nearest: Well _____ �c1e.................Foundation ......0----------- Prop. Line . ----------...... } <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date _______________._._-.-____________} <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------i------------- ------------------ -----• 3 <br /> Disposal Field (Sp cify Requirements) ---------------------------- <br /> ----------- ----- <br /> - ---------------------------------- ------------------------ <br /> (Draw existing(dnd&6luired addi on 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, 1 shall not employ any person in such manner <br /> as to becomes to orkman's Compensation laws California." <br /> Signed ------ -- — -----Jf " Owner <br /> By ------------------------ - - ----- ------ -- -- ------------ -- -------- ----- Title <br /> (If a an owner) <br /> EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ' ----------------------------------------- ----------------- DATE ---- ! r -------------- <br /> BUILDING PERMIT ISSUED ---------- r- ------ -- -- ----- ---- -- --------------------------------:--------------------------DATE - 4 = <br /> -------------------------------------- <br /> ADDITIONAL COMMENTS <br /> - ------ ------------------------------------------------------------------------------------------------------------------------ - ------ <br /> ----------------------------------------------- --- -------------------------- --------------------------------------------------------------------------------------------------- -- -- ­­ <br /> --------------- -------------- ------ <br /> ------ ---- <br /> �.� -Final Inspection by: ------ <br /> = --------------------------- ------------ -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />