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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT� - -- -��.-�3D--- - Permit No. <br /> ~` (Complete in Triplicate) <br /> --------------------- This Permit Expires 1 Year From Date Issued Date Issued -r 7_ -,`l. <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 com li ce with County rdinance No. 549 and existing Rules and Regulations: <br /> J <br /> JOB ADDRESS/LOA ON . r� -------- - ----------------------------------------_-CENSUS TRACT -----------------------_. <br /> Owner's No �LG--------- ---------------------------------------------------Phone <br /> Address ------A �- --------------- - ----------%-------------------- city ------------------------------ ------------------- ------ <br /> Contractor's Name -----__-- License #�. 7g g3- Phone' ---- --�---------- <br /> Installation will serve: Residence Apartment House❑ Commercial -❑Trailer Court ;❑ <br /> Motel ❑Other ---------------------------------------- <br /> Number of living units:___--1----- Number of bedrooms -;4-----Garbage Grinder'___._-- Lot Size - --x Zos <br /> Water Supply: Public System and name ------------------------ ---fc-I <br /> ---------------------- ---------------------------------------PrivateCharacter of soil to a de th of 3 feet: Sand' Silt a Peat Sand Loam Cla Loamp ❑ ❑ Y ❑ ❑ Y ❑ Y ❑ <br /> Hardpan ❑ Adobe 'FiII 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,) 9,t <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size---------------------- ------------.--.......... Liquid Depth -_---_.-_---_---------. <br /> Capacity -------- --- ------ Type -------------------- Material-------------------- No. Compartments -----------------_-- �y <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING <br /> ---.----- .._.--.-_.LEACHING LINE [ ] No. of Lines .----------------------- Length of each line---------------------------- Total Length -----------..---.-._---._.-- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distance <br /> ------------------------------ ---_._Distance to nearest: Well _.------------------ Foundation ------------------------ Property Line --_---.--___---.----- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C <br /> Water Table Depth .------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .--------.------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date <br /> Date ---------------------------------- <br /> Septic <br /> ____----_--_-_-.----------__-----Se tic Tank IS ecif Requirements) -------------------- -- --------- ) <br /> � l- <br /> -# <br /> 3 ` <br /> Disposal Field (Specify Requirements)s <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 becomes b}ect to Workman's Compensation laws of California." <br /> Signed ------ .S tOwner <br /> ByK----- ------------------------------------------------------------ Title �t.--------------------------------------`------------- <br /> (If other than owner) N <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -------- --- C�► -- -------0"--�t----------------- ---------------------------------- DATE .' ~ ------------------ <br /> BUILDING PERMIT ISSUED --------- ------ -------------------------------------- -------------------- ------ <br /> ---------------------------------------------------- <br /> - ---•------- <br /> ADDITIONAL COMMENTS -__ -__ -- - <br /> --- -- - - - '(r ----- -- ----- s j-9 - --- ----- <br /> ---------------------------------- <br /> ------------ ----- <br /> - ----- -- --------- <br /> ------------------------ --- <br /> = ---� s ----- ----------------------------------- <br /> ------- <br /> FinalInspection by: ----------------------- -------- --------------------- ------------------------------..Date _32 --Q--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />