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FOR%MICE USE: 3 <br /> APPLICATION FOR SANITATION PERMIT <br /> ' (Complete in Triplicate) permit No. _'S� _.. <br /> --------------------------------------------------------- <br /> o___________._.____ Date Issued_______________________________ 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 <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION : ' I �'"-------------------------------------------------CENSUS TRACT --------------._---------- <br /> Owner's Name ,--- ------------ -1-------------------------- ------Phone ------------------------------------ <br /> Address ? t• City A. <br /> ---------------- :---------------------- <br /> Q- -.. C .______ ,_______,_____._:______.LicenseContractor's Name -- .— <br /> Installation will serve: Residence [2 artment House❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of livingunits: Number of e)drooms._ ____ _Garbo a Grinder Lot Size.Se�� __ <br /> ger?. <br /> Water Supply: Public System and name __ _-____ ________4 =- 4+_ r ------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe T 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 /> NEWINSTALLATION: (No septic tank or seeps pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { I SEPTIC TANK:[l.} ze_4-, ___ ___ Liquid Depth iCa acit ypo. Compartmentsp Y T e �1 �_ ter�al _ h ---- ------ <br /> Distance to nearest: Well _______-_ `--_.________.Foundation _____�3�__ .- Prop. Line 1�> _r__________ <br /> LEACHING LINE No. of Lines ___. <br /> �}� �_____.__ Length o each line_ .l _ "____ Tota! <br /> fLength/ ---�._�_/ <br /> - -------------- <br /> ��// 1.9J <br /> 'D' Box _Yc <br /> __ Type Filter. Material _ ack-_-____Depth Filter Material __________-----------------------•._ <br /> Distance nearest: Well ___.__�---~-_______-_ Foundation - ---a________________ Property Line ,�.__- <br /> SEEPAGE PIT Depth ---------- Diameter. -��___ Number -----_A---------------- Rock Filled Yes o i❑ <br /> Water Table Depth ` _ Rock Size ________________________________ <br /> �# Distance to nearest: Well ----------- ----------------------� Foundation _127--/----- Prop. Line __�J.-_--__. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------.-------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ----•----------------------•-----------------------_--- <br /> Disposal Field (Specify Requirements) ----------- ---•------------------------------------------------------------------------------------------ ----------------------.-- <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 --------------- --- -- ---- Ownea_ljlo� <br /> BY ,. � -�• ------ --------- Title -- - - <br /> - --- -- - ----------------- <br /> (If other than wn r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _-- - -------------------------------------------------------------------------------- DATE ---S"�$" y---------------------- <br /> BUILDING PERMIT ISSUED ----- - ----------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------- ---- ----------- --------------------------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------- <br /> ----------------------------------------------------------------- <br /> Final Inspection by: ----SAN JOAQUIIvL--- o---------------------------------------------------Date - :----�� ' --- ----------- ---- <br /> CAL HEALTH DISTRICT <br /> ' E. H. 9 1-'68 Rev. 5M C�' <br /> i <br />