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FOR OFFICE SE; r- <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. 7G ____ <br /> -- ---...-------------------------------------- <br /> --.-_____________ This Permit Expires ] Year From Date Issued Date Issued kr -__7Q <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/LOCATI /�/Q �- ----e- --------------------------------------------------- ---CENSUS TRACT -------------------------- <br /> Owner's Name Phone ------------------------------------ <br /> Address l ------ city <br /> / --------------- ---------------------------- <br /> Contractor's <br /> ---- • •---•- <br /> Contractor's Name _.. - ------ -- ----------------------------------------License fll.- G -.__ Phone -----------�•�/-t•a <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court Fl <br /> Motel ❑ Other ------------ ----------------------------- <br /> Number of living units:________ Number of bedrooms ---�_____Garbage Grinder Lot Size ---------_____________ <br /> Water Supply: Public System and name ------------------------------------------------------ --------- ----------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe IV Fill 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 [ I SEPTIC TANK'[,�]r Sze_. l Liquid Depth <br /> a �1 �J. <br /> Capacity Type p Y -- Yp P-lie,-(---4,AfMaterialak�c--& ____.- <br /> No. Compartments _ _______________ <br /> Distance to nearest: Well ____________________________________Foundation -147--1---------- Prop. Line ------------ <br /> LEACHING LINE [ No, of Lines _ ------------___ Length of each line--- _J�r7-- Total Length ----------- <br /> 'D' Box VAS_--- Type Filter Material _ _Depth Filter Material __-/JP-i--______________ __ _ ______ <br /> Distance Ito nearest: Well ________________________ Foundation ___/C7. .......... Property Line _��-___-__.-._.. <br /> SEEPAGE PIT Depth _ ., _________ Diameter33`1_____ Number ----- ------ Filled Yes �No <br /> Water Table Depth 1I/----------------------------------------Rock Size -2-/----------------- <br /> Distance to nearest: Well ------/.2­Q_------------------Foundation ---/_V__f------ Prop. Line __$�___-._.._.- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------_------------------------------------ Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- <br /> DisposalField (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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------------------- ----------- Owner <br /> - ----------------------- ------ - --- <br /> BY ---- - --------------------------- Title <br /> (If other than ow r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE - ` `~ ._ <br /> BUILDING PERMIT ISSUED -- - ---------- - --------------------------------- ------------------------------------------- <br /> ---- --------------------- <br /> ADDITIONAL COMMENTS <br /> -----------I------------------- ----------------------r-------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------- ----------------------------- ------------------------------------------------------------ ------------------------- <br /> ------ --------------------------------------- -- <br /> --- --------- ---- DateFinal Inspection by: SAN JOAQUINC <br /> C <br /> DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />