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gip... <br /> FOR OFFICE USE: - " <br /> APPLICATION FOR SANITATION PERMIT T S y <br /> --------------------------------------------------------- Permit No. <br /> (Complete in Triplicate) 1,_______3 <br /> ---------- - <br /> Date Issued _ -_ --T <br /> ------------------"------_-.------------.---------------- This Permit Expires ] Year From Date Issued <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------ - --- - ------------------- -- EL f C Z - CENSUS TRACT�--------------p---r-1--- <br /> ----- <br /> --e ---- PhoneOwner's Name <br /> Address . � l ( 1 of /2r'ls _ -------•--. City_!._a/ N!l=GP9 --�s -------- / �3 <br /> Contractor's Name -- - ---e.- /-/- -------------------•-_---__--.License #( T�?- �c --- Phone "�L1y <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> j Motel ❑ Other --------------------- ---------------------- <br /> Number of living units:_L-________ Number of bedrooms _______Garbage Grinder ------------ Lot Size .-- -Q- - =" '------ <br /> Water Supply: Public System and name ---------------------------------------------------------•-----------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: SandSilt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes, type __-________---_____.-___.- <br /> i <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 - 411 -2 <br /> Capacity /_17_00----- Type Compartments _�r______----__ <br /> Distance to nearest: Well ------ -- ------------------Foundation ____t_i _.__._-____ Prop. Line ---6 _____-----_ <br /> LEACHING LINE [ ] No. of Lines ----3----"---------- Length of each line........ -------- ----- Total Length _C*;Ll P______________ <br /> D' Box - Type Filter Material r --- <br /> Depth Filter Material __ _-----------.____________________ <br /> Distance to nearest: Well -----6M---------- Foundation -1--c-)-------------- Property Line. b.___................. <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number -- __ ----------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------- --------.- Prop. Line -------.__...____-.... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ----------------------------- Date ________-_____________________--} <br /> SepticTank (Specify Requirements) -------------- ------------------------------------------------------------------- ------------------------ ----------------------------- <br /> i Disposal Field (Specify Requirements) --------------------------------------------- <br /> I -------------------------------------------------- ------------------------------------------------------------- ------------------------------------ ------ ----------------- <br /> -------------------------- --- ----------------------------------------------- ----------- ------------------------------------- ------------------------------ -------------------------------------- <br /> (Draw existing <br /> 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, 1 shall not employ any person in such manner <br /> as to become subject to Wo on's Compensation laws of California." <br /> Signed <br /> i{ ------ - --------`----------------_-_---_--_---4-- --------------------------- Owner <br /> Title --- <br /> ------ ----------------------------------------------------------------------------- --------BY _ ___ ------------ <br /> (If <br /> __ _____(If <br /> 9ther than owner) <br /> 4 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- --- -- ------ ----------------------- DATE ....- � _2� <br /> ----------------------------------- ------ - - 7`-------'---_20?------------------ <br /> BUILDING PERMIT ISSUED ------------------------------------------------- - ------------------------------ --------------DATE -------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------- ------------ ----------------------------------- <br /> ---------------------- --- ---------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------- ---- -------------------------------------------- <br /> -------------------- --------------------- --------------------------------- -- <br /> - � ----------=------- <br /> Final Inspection b --------------------------------------------------------------------------------- <br /> --- Date -- ~.ate ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> x <br /> E. H. 9 1-'68 Rev. 5M A <br />