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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT p <br /> - - - Permit No. .�_.��---C <br /> (Complete in Triplicate) <br /> ---------=----------------------------------------------- <br /> ---------------I This Permit Expires 1 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` :coornpilance' with County Ordinance No. 549 and existing Rules and Regulations: <br /> 2. h"- a�-� <br /> JOB ADDRESS/'LOCATION.,.------------- ------0 ------ - - ENSUS TRACT ------------------------- <br /> Owner's Name ------ <br /> -'.�--------------------------------------------------------•-------------------Phone _SZKS _--/�-72--•---- <br /> Address ---------"/,/.47,1 � ------`w--------�� - �- --------. Cit <br /> Y i ----------- <br /> Contractor's Name -----------------------License # i -� - Phone <br /> Installation will serve: Residence [A Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other <br /> Number of living units: --.- Number of bedrooms ----Z---Garbage Grinder ------------ Lot Size ------12 0ac.................... <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 Flit Material ------------ If yes, type ---------------------------- <br /> (PI'ot 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 t �' <br /> ppi permitted if public sewer is available within 200 feet,) � <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.X Size_-�y(-_ ----------------------------- Liquid Depth ------ - <br /> Capacity /ZPo Type 2;�� �Material_Zr�<���_ No. Compartments __-,� --....:..-. <br /> Distance to nearest: Well -__-'__----9f0_/---------------Foundation --_- _ ------ Prop. Line __-e*�`"`J <br /> g � f <br /> LEACHING LINE X No. of Lines -__ - -- ----- ---- Length of each line---------l--�------------- Total Length -__-_fQ_--..-.----- <br /> 'D' Box ---/----_ Type Filter Materia --__-/lam---Depth Filter Material _--.--- <br /> Distance to nearest: Well ------ O---------- Foundation -.-----�0--------- Property Line -_ ------------- <br /> SEEPAGE <br /> _--._-----_ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -------_------- Number ----------------- ---------- Rock Filled Yes [] No <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------- ---- Prop. Line --------___------- <br /> REPAIRfADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------------------------------------------------------------------------------------•----------------------- ; - f <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------- ------------------------------ --- ------ <br /> r <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I------------------------ <br /> --------------------I------------------------- -------------------- - ----------------------------------------------------------- --- ----------- -------------------------------------- <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 k <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 becom biect to Workm 's Compen n laws of California." <br /> Signed .--- - ---- Owner <br /> -------- <br /> BY ------- ------- ----------r- ---------------------- Title ---------- <br /> (If ther#han owner} <br /> --------------- <br /> --------------- ------ - <br /> FOR DEPARTME T U E ONLY <br /> APPLICATION ACCEPTED 8Y ------------------------------------- - ---------- ------ DATE ---- � � ---•--- <br /> 8U(LDING PERMIT ISSUED -------- -- ----------DATE ------------- ------ <br /> ADDITIONAL COMMENTS ----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------- ----------------------------------------------------------------------- <br /> � <br /> Finai Inspection b ---- ------------ <br /> SAN JOAQUIv LOCAL HEALTH Dl!e--- Date ------------------------------------- <br /> E. <br /> ---`-E. H. 9 1-'6S Rev. 5M { <br /> - <br />