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-FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> r------------ -- --------------------- - Permit No. <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued 4____7:_7.1.— <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/LOCATI N - -CJ--- -- ,--- `" d /?W----------------------- TRACT __�- f -------- <br /> Owner's Name '�� '� -Phone X� � . ---•---- <br /> Address -- -----901 ---- �'---- -0---- city --- r----- ----- <br /> ----- <br /> . <br /> ----------------- <br /> Contractor's Name ---101_::; -2__P_.k- ----------------------------------------------------------.License # ------- --- ---------- - Phone ------------------••-------_- <br /> Installation will serve: Residencek Apartment House❑ Commercial []Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----l------ Number of bedrooms ________Garbage Grinder ------------ Lot Size ___________________________________________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------PrivatsjV <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ 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 _________________________- ' > <br /> Capacity ---- ------------•-- Type -------------------- Material---------------------- No. Compartments ------------_--•---- <br /> Distance to nearest: Well ------------------------------------Foundation ------------ --------- Prop. Line __-_.___._......._...- <br /> LEACHING LINE [ ] No. of Lines _ --------- -- Length of each line_______________ Total Length ------------ <br /> 'D' <br /> _____- _.'D' Box ------------ Type Filter Material ____________________Depth Filter Material -.-_--_-________.--_-___---__......,....____ <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ___-__--____---___-_____ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ NumberRock Filled Yes F] No C]---------------------------- <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------.-------_------------------) . <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ---A, /______ <c + ►_______________________--------------- <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 /> "1 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�Compens tion laws of California." <br /> Signed --_ _ c !'c,-.cs- -- ------------------------------- Owner <br /> BY --------------------------------- --------------------------------------------- --- <br /> ------------------- T -- <br /> Title -------------- -------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _____________ DATE S"Z_'._�7__ _________._.____._ <br /> -- -- ------------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------- ----------------------------------------------DATE ----------------------------------------- <br /> ADDITIONALCOMMENTS --- -------------- -------------------------- ----------------------------------------- ------------------------------------------ -------------------------- <br /> ----------------------- ----------------------------------------------------- --------------------- ------------------•------------------------------- --------------------------------- --------------- <br /> ----------- - <br /> ------------------------------------------------------------- -- - <br /> - ------------ <br /> Final Inspection by: -- --- ( � --------------- -------- Date SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />