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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- . <br /> (Complete in Triplicate} Permit No. <br /> ---------=----------------------------------------------- <br /> Date Issued __.J_�a <br /> _----.--I--- -------------- This Permit Expires 1 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 /> E <br /> JOB ADDRESSAOCATION . . � I---1_/ [./ b. L��L.�iY�c1 ��`-�--------------------------------------CENSUS TRACT ------------------- ------ <br /> Owner's Name -------- --------` ( _ __ /_�1� 1 HR---------------------------------- -- --- - ------ -------Phone �4 `� � -------- <br /> Address 1'[ � = 1171_}71<�- '- ----------------- CitY ��I' � <br /> Contractor's Name ------- ------f 0110Q----------------------------------------------License # -------------- ------- - Phone ------------------------------ <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ,❑ <br /> Motel ❑ Other ------- -------------------------------•--- <br /> Number of living units:...../----- Number of bedrooms -. __.Garbage Gri er ___. Lot Sze _...$94 . <br /> }� _- --------------•-------- <br /> Water Supply: Public System and name -------------ex,&--4 ------ - <br /> Ex x - -----------------------Private <br /> 44 1 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobeill 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 --_.------------------_-- Qp <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' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------- <br /> Distance to-nearest: Well= --7----_---- Foundation ----------------------- Property Line ------------------------ <br /> SEEPAGE PIT [ Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------- ------------- <br /> I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date _---------------------------------) <br /> . i <br /> Septic Tank (Specify Requirements) ---------- ,. ._ _- 'r�� i __.__0&-------------------- - <br /> Disposal Field (Specify Requirements) ------------ - - -------------------------------------------------------------------------------------- [ <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 7Compesation laws of California." <br /> Signed ----------------------------- Owner <br /> BY - - -- - - -- ---- --------- Title _.. 5 <br /> -------------------------------- <br /> � {lf other than owner} FOR DEPAitTS NLY <br /> APPLICATION ACCEPTED BY --------------------------------------- <br /> ------------ <br /> -------- - ---------- - ----- <br /> --- - �- I— DATE _..__�/��:f �---------------- <br /> BUILDING PERMIT ISSUED ----------- ------------ -------DATE ..--------.-----___ <br /> ADDITIONALCOMMENTS ---------------------------------- -- --------- -------------------.-- ---- ----- --------------------------------------------------------------•- --------- <br /> ------------------ <br /> -------------------------'- --------- --------------I------------------------- --•----------------------------------------- ------------------------- ---- -------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------- / ------ ------ ----------- --------------------------- <br /> --------------------------------------------------------------------------------------------------- ----- = ------- <br /> -------------------- <br /> - - <br /> Final Inspection by: ------------------------------------------------ ------------ ---- -- -- r ----------Date ' 4- �1 <br /> SAN JOAQUI LO L HE TRICT . <br /> E. H. 9 1-'68 Rev. 5M <br />