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''`' `FOR OFFICE USE: Z'" <br /> APPLICATION FOR SANITATION PERMIT <br /> -- -- -- ------------ ---------------------------------- Permit No. -� _= <br /> (Complete in Triplicate) <br /> This Permit Expires i Year From Date Issued Date Issued <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 /> JOB ADDRESS/LOCATION .--� - �__ °' ---- -G-------------------------- -- CENSUS 'TRACT --�--�-�- -_.--- <br /> Owner's Name ,�=if s : -------- •----------------------------------------------------------- Phone ------------------------------------ <br /> Address - °37e{�d """ --------- ---------------------- City e----- ------------------------------------ <br /> Contractor's Name 1. 'a €- -------------------------------------`------------------------------License # ------------------------ Phone ----------------------------- <br /> Installation will serve: Residence �3 Apartment House-[:] Commercial[Frailer Court ❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units_/-------- Number.of bedrooms .----Garba-ge Grinder ------------ Lot Size MIt, --------------------------- <br /> e <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------------------- -------------Privat z <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam-,f] <br /> v Hardpan W) Adobe'❑u Fill Material ------------ If yes,type --------------------------- <br /> (Plot <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:[ I Size------------------------------------------ ----- Liquid Depth ----------------------•-.-� <br /> Capacity ------------------ -- Type --------------- ---- Material---------------------- No. Compartments -------____------_.I <br /> Distance to nearest: Well.------------------------------------Foundation ----------- ---------- Prop. Line .-..............------Ln <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 ------------------------ Foundation ------------------------ Property Line. ----------------------- - <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number .--------------------------- Rock Filled Yes '❑ No i❑r. <br /> Water Table. Depth ----------------------------•----------:--------Rock Size ---------- f <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev.(Prev. Sanitation Permit# ------------------------------------------------------ Date --------._.----.-:----------------} <br /> Septic Tank (Specify Requirements) --------------------- -- - - ---------- - --�----------1-^---�-3-";t-�-S`!----- ----�- --:---------•------------•--•- � t <br /> YYY <br /> Disposal Field (Specify Requirements) -� r�_. __ -z. ------- ----------- . E <br /> -------------------- -----------------------------------------------------------------------------------------------w------------------------ <br /> - -------------------:-------------- ------------------------------------------------------: ---•------------------------------------------------------- -- ----------- ------------------------------------ <br /> (Draw <br /> ------- ----- ------- <br /> - - - -------- - - <br /> (Draw existing and required addition on e6verse`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 becom su i ct to Wojjrkmp�p's Compensation laws of California." <br /> Signed --- �- -------- <br /> Owner <br /> BY --------- ------------------------------------ ------------- - ------ Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY F <br /> APPLICATION ACCE=PTED BY ---,� ,z_y ---------------- ---_-. DATE il- '_7Z7----------- <br /> >I <br /> -------------------------------------------------- <br /> BUILDING PERMIT ISSUED ---. -------------------------------------------- -------DATE -------------------------------- - <br /> ADDITIONALCOMMENTS ------------------------------------------- ---------- --------------------------------------------------------------------------- --------------------------- ] <br /> - ----------------------------------------------- ----------------------------------------------------------------------- -- ----- ------------------------------------------------- - ---------- <br /> ---------------- ------------------- -------------------------- <br /> --------- <br /> ------------------------------------- <br /> Final <br /> ------------------------------ ---- - <br /> Final Inspection by: t- --------------------------------------- ----------- --------------------Date ------------------------- <br /> SAN <br /> --f----�------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />