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FCS OFFICE USE: APPLICATION FOR SANITATION PERMIT '/ <br /> Permit No: .. <br /> -------- ----------- ------ (Complete in Triplicate) <br /> ------------------------- <br /> --------- --------------------- __-. <br /> Date Issued �7X <br /> This Permit Expires 1 Year From Date Issued <br /> --------------------------------- ----------- ----------- 4 <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 /> 1 �'- _q Phone, ----• <br /> _ Q _ L(>t- ------�------ -- ------ ----- ---- CENSUS TRACT --- <br /> JOB ADDRESS/LOCA " -� ------- <br /> TION -- - <br /> ------------ - <br /> Owner s Name -._,f'l� l n4a_- [ ------� _ <br /> /`-' -=--------,-- City / <br /> �` ll/�-crJ <br /> Address - -� �- ` ----------- - - <br /> Contractor's Name ' - /'� = License # � r� Phone1 - � ' <br /> Installation will serve: Residence ® Apartment House-[] Commercial:❑Trailer Court ',❑ <br /> i <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------ ---- Number of bedrooms -__3---Garbage Grinder ------------- Lot Size ..- --:----------•---- <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------------ <br /> __-- ---- _ --------------------Private [ <br /> QS <br /> Character of soil to a depth of 3 feet: Sand'[' Silt❑ Clay [I Peat El Sandy Loam ❑ Clay Loam E3 <br /> Hardpan ❑ Adobe'❑ Fill Material _.---------- if yes,type - <br /> (Phot plan, showing <br /> 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'f ] Size......... 1d------ Liquid Depth _=6 -•-------- <br /> D G''� Material-- ? No. Compartments - <br /> Capacity ��_C--------- Type t <br /> Distance -to nearest: Well ------- -/------ ---------Foundation ---��-- ------- Prop. Line __-..;--------- <br /> C�- ------ Total Length : ��l•----------- <br /> � LEACHING LWE [ ] No. of Lines -.--__��___--------- Length of each line--__ "--, - <br /> '712 <br /> ' -- ----- Type Filter Material <br /> Distance'. <br /> Filter Material ------------ <br /> ' D' Box r t 4 - Property Line --•-- --- <br /> Distance' to nearest: Well _-- --------- Foundation ------l- "-------.- p ty <br /> SEEPAGE PIT Depth ---- Diameter ---------- ---- Number ---------------------------- Rock Filled Yes El No 0 +' <br /> t Rock Size ----------------------- ------- <br /> Water Table Depth ---- -------------------------------------- ---- <br /> `( -Foundation --------------------- Prop. Line ------------------- - <br /> Distancelto nearest: Well --------------------------------------- <br /> Date(Prev. Sanitation Permit# ------------------------- <br /> Its) <br /> ------- --------------- Date -------------------•------• 1 <br /> ` i} <br /> Septic Tank (Specify Requirem�nts} ------------------------------------------------------------- <br /> ----------------- <br /> Disposal Field (Specify Requirements) ----------- ------------------------------------ <br /> - ----------•----=---- <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 /> p "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 toWo. man's Compensation laws of California." <br /> Signe ----- ----- - ---- - <br /> - --- ---- - - <br /> -A <br /> --- - ---------- -r---- --7------------------------------ Owner <br /> r ---------------------------------------- <br /> BY -- " =� t� J Title ------ ---- - ---------- ----- <br /> -A- <br /> (If o er an owner) <br /> ' FOR EPARTMENT USE ONLY Q <br /> DATE / - 3 !�•---------•--------- <br /> APPLICATION ACCEPTED BY --- �------ --- "---- - - ------------------------------------ ------------ -------- DATE <br /> -------------•----- ------------ .--->; <br /> BUILDING PERMIT ISSUED __ <br /> f ^A ------ <br /> - ..........- ---- --- <br /> --------------------------- <br /> ADDITIONA CO ENTS ---� �R - � ' <br /> 1yi <br /> -----Q ►`',•'' r` __- �- •ol -P ��xt,. lam-- ------------- <br /> e _ _"" <br /> ---------------- <br /> --------------------------------------------------- <br /> - ----------------------------------- -------------------------------------------- ------ <br /> Final Inspection b --- -- ----- --------------------------- <br /> ------------------------------ Date _..- 3-"`�`/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M —_ <br />