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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' <br /> Permit No: .�z:-S-�--�-� 1 <br /> ----- - ----------- ------- --------------------- (Complete in Triplicate) <br /> ------------------------ Date <br /> ----------- Issued - --=-----�-•---� <br /> --------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued , <br /> Health District for N <br /> a No..5A9 and existing Rulestruct and andl the work herein <br /> Application is hereby made to the San Joaquin Localnd Regulat ons- <br /> T lication is made in compliance with Y <br /> described. This ap,p,; . � •. 2`fC?-?mo0 <br /> OS ADDRESS%LOCATI -----a os.�`{�� �� �u-l�_ CENSUS TRACT <br /> C � /Z� ---Phone --- --- <br /> Owner's Name -"_ <br /> ---------. Ci <br /> j --------------------------------------- I <br /> Address ----- ---------- ----------- <br /> ------------ <br /> l- - tY <br /> Contractor's Name ._- <br /> -- License # - _ 8 -y Phone . <br /> Installation will serve: Residence %Apartment House[] Commercial ❑Trailer Court ❑ <br /> m units:.- Motel ❑Other -------------------------------------------- <br /> Number of living 1----- Number of bedrooms _ __..Garbage Grinder --_-____--- Lot Size ___"___._r---_-- Private - <br /> ------ -- --------------------------------------- <br /> Private <br /> Water Supply: Public System and name --------------- -------------------- ------ - - - <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ;K Clay Loam ❑ (� <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- y <br /> i <br /> size of lot location of system in relation .to wells, buildings, etc. must be placed on reverse side.}, <br /> (PI'ot plan, showings e <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if <br /> public sewer available within 200 feet,) <br /> SEPTIC TANK.� r - Liquid Depth __.'il------------------ <br /> PACKAGE TREATMENT [ ] � Size_ ___�__ ___/-I` __"____- ---- - - q p <br /> Capacity _�szda Type��`-`�'----- Material --- No. Compartments <br /> _A------------- <br /> t __Foundation .___ 0- 1-------- Pro Line ______��'___1.___-----. <br /> Distance to nearest: Well -------- �-------------- ----- � P' <br /> LEACHING LINE No. of Lines --------I- _______._ Length of each line-------_ B-b--`--___ Total Length - ------ <br /> ZZ <br /> i 'D' Box ----l�------ Type Filter Material -----A---------•-----Depth Filter Material _-- --Al-------•-------- .............. ,1 <br /> Distance to nearest: Well ----_-�P" --- ---- Foundation ._______L_ _�....... Property Line ___4F ­ <br /> -------- -------- r <br /> S Number _.------- -- <br /> Q2 -_-_--"-____ Rock Filled Yes a <br /> SEEPAGE PIT 1(] Depth -___. -- "-___,_ Diameter _ .., <br /> r - Rock Size _ l <br /> Water Table..Depth• ------___—_----. •--------------------- <br /> --------- <br /> � <br /> Distance to nearest: Well --------_- -_f_QP_'----------------Foundation ---10 ---- Prop. Line -- ------------•--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit s# -------------------------------------------- <br /> Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----_-"------------ -------------------------------------------- <br /> Disposal Field (Specify Requirements) _______-__ <br /> ------ ----------------------------------------------------------•----------- ----------------------------------------- - --------- <br /> P <br /> (prow existing and required addition on reverse side) <br /> I hereby certify P that I have prepared this application lication 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 Compensation laws of California." <br /> Signed ------ ----------------------- Owner <br /> ---------------- <br /> By <br /> --------------------------------------------- <br /> Title -- <br /> F G <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ----- - -- -------------- ---------------------------- ------------------- DATE _S'�'.;_7S• 9"--------------- <br /> -------------- - - <br /> BUILDING PERMIT ISSUED ------------------ ------------------------------------- -------DATE --------------------------- <br /> ADDITIONAL <br /> ------------------- ----ADDITIONAL COMMENTS ----------------------------------- -- ---•------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------- ----------------------------------------------------------------------------- <br /> ------ ----- - - ------ -- --------------------------------------------------------------------------------------- -------- --- <br /> --------- <br /> ----------------------- - <br /> - - --- -----------.Date -- � ----- - ----- -- —---------- <br /> Date <br /> Inspection by: ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> z u 0 1-'68 Rev. 5M <br />