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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .2 --fis <br /> Permit No. ---- - -- <br /> `*` <br /> . (Complete in Triplicate) <br /> ---- -- ---- /--- 7 Z <br /> --------- / \ This Permit Expires 1 Year From Date Issued Date Issued _ -_____________ <br /> Application is hereby made to the San Jdaquin 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 ----------- a--�"U------ -----H-L.G-1-1._anI A�(---- ----- ----CENSUS TRACT -------------------------- <br /> v <br /> Owner's Name ----------- A -T�_/ -----------IE-CA---T---------------------- --------- -------Phone <br /> Address ------- '"�"�- ' C U, . -IE-------------------------- City --- ----------------------------- <br /> ------.License # _ _.~' I_ 3�---41,1- _A__ <br /> Contractor's Name ------.j/I�L_�4_+<A_1_�_____M__V_�-�-�� _ ___`�_ �_ Phone_ � � <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ i <br /> Motel ❑Other p F FI C e <br /> Number of living units:------I----- Number of bedrooms _____ !___Garbage Grinder _ti!p__ Lot Size ____________________________________________ <br /> Water Supply: Public System and name ---------C-1_T_Y-----&I_At�I_T P-C_*�---------------------------------------------------Private ❑ F <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 /> J <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth _____________________,_._.. Q <br /> Capacity __.qA4_------- Type tea,-__ Material__. , No. Compartments __�,............. (1� <br /> Distance to nearest: Well ____ ' ' V--- ---------Foundation ______1_d_______ Prop. Line _____A3.............. <br /> LEACHING LINE [ ] No. of Lines ----------I------------ Length .of each line---------C_o _ Total Length -------!_a.............. <br /> 'D' Box _1JS2A___ Type Filter Material _____]__51--_____Depth Filter Material _______ -i_I--------------------_----- <br /> Distance to nearest: Well __________ _____ Foundation ------------------------ Property Line _-__-___._______ ....... <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest; Well ---------------____________ _____ ______Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION <br /> _______..________._REPAIR/ADDITION(Prev. Sanitation Permit# _____________________________________m______ Date ---_______________________________} <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------•----------------------------- <br /> Disposal Field {Specify Requirements) ------------------ ---•---• -•-------------------------------------------------------------------------------------- ---•----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I <br /> ------------------------------ ----------------------- ------ ----- <br /> - --- - ----- ------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required additiori 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: I <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 /> BY ` ��rn --------- Title - ----- ---------------------------------------------------------------- <br /> (if other than owner} <br /> FOR DEPARTMENT USE ONLY c� <br /> APPLICATION ACCEPTED BY ---- --____-- --- DATE --- ---/___---.----------------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------- - -------- ------------------------ <br /> -------DATE ------------------------------------------ <br /> - - <br /> ADDITIONALCOMMENTS --------- - - -- ------------------------------------------------------------------------------------------------------- ------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - _ <br /> Final Inspection b : --------.-- -- — ---•-_-_ ------- <br /> p Y Date . 7� - --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F. H. 9 1-'68 Rev. 5M <br />