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- FOR OFFICE- --USE- - : <br /> APPLICATION FOR SANITATION PERMIT <br /> - ---- -------- - - ------ <br /> (Complete in Triplicate) Permit No: 7 ---""�� ____ <br /> --------------------------- This Permit Expires 1 Year From Date Issued Date Issued _-CAU✓__.. <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 Ordi ance No. 549 and existing Rules and Regulations: <br /> // -- -- -- - --1.4 <br /> JOB ADDRESS/LOCATION --------------- 1-- ----- --- ------ <br /> 2)e__V---- CENSUS TRACT __-_-_-_-_____________.__-- <br /> ��II -- n <br /> Owner's Name -------,�,Am----- -- ------ - -- ----------------------- Phone <br /> Address _1. ---------- - City <br /> l <br /> Contractor's Name ---------- s-< ------ -------- -------- --- .------- -- --.License #1JIf3-2� Phone ---------------------.------.• <br /> Installation will serve: Residence Apartment House❑ Commercial ;❑Trailer Court <br /> Motel ❑ Other ---------------------------------------- -- <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 p Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ \ <br /> Hardpan ❑ Adobe ❑ 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 ----__-_-___.___._.,--_-- L3f <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------- J <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----------------_-- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-------- --------------- Total Length -----------------------.__.. <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -------------------------------------------- <br /> Distance to nearest: WeII ________________________ Foundation ______`_________- -- Property Line _____--_______-__._.___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ 1 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> --------------------Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line --______________..__.. 7, <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _--_--_-.--____________________________-___ Date-_-_______________________-____---1 <br /> Septic Tank (Specify Requirements) -------------------------------------- -------------------------------------------- <br /> Disposal Field (Specify Requirements) ------ � - • � i <br /> _ rr___ -__ �._______ <br /> - - ---- - ---- -- ----- -------- - -------------- -------- - - <br /> Q - ^^- -----=---------------------------------------------------- ------------------------ <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 /> ---- -- ---------- - ---- <br /> BY --------------------------- - --------- ------- ----------- Title <br /> "------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - -` - ----------------------------------------------------------------------------- DATE --- .3---------------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------- -------------DATE -- ----- - --------- <br /> ---------------�------------------------ - ----------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------- ---------------------------------- <br /> ------------------------------------------------ ----------- ------- ------------------------------------------------- -------------------------------------------------------------------- <br /> ---------------------------------- - -- <br /> Final inspection by: 4 -c: --------------------------------- -----------------------------Date ---------- ----- <br /> SAN <br /> -------- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />