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FOR OFFICE USE: f I <br /> , <br /> APPLICATION FOR'SANITATION PERMIT <br /> �6 Permit <br /> No <br /> - ---- - <br /> -- -(Complete in Triplicate) <br /> --------------- --------------------------------- ------ ,; t <br /> --------------------------------------------------------- � �, " 3 Permit Expires 1 Year From Date Issued <br /> Date Issued _= ,9 <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 /> J013 ADDRESS/LOCATION _ ------�__-_.-----.r_..._ -------CENSUS TRACT -------------------------- ' <br /> /yA-� <br /> Owner's Name ------- -- -- -�1 E ► ' i Phone --- <br /> Address 5'__?r____� w_._: Cit s e S -------- <br /> Contractor's Name ------ C`� --e'ra--------- ------.License # ------------------------ Phone -------------------_-_... -- <br /> - .: - <br /> Installation will serve: ResidenceXApartment House❑ Commercial [jTrailer Court <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units: --- Number of edrooms ___ ------Garbe - <br /> Grinder ------------ Lot Size __,#' __ .f�:{}-------------- - <br /> Water Supply: Public System and name -- ---� i -----fJ� -t --- <br /> -�i rr ------t4G='-----------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> 6 <br /> Hardpan ❑ 'AdobeW Fill Material ------------ If yes,type ....------------------ <br /> (Plot plan,ishowing 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'[ ] - . Size ----------------------------------------------- Liquid Depth ---------------------.----- O ,r <br /> { Capacity -- ---------- Type -------------------- Material---------- -- -------- No. Compartments ---=------- ----•°---- <br /> Distance to nearest: Well ------------------------------------Foundation ------- -------------- Prop. Line ----------------..--- <br /> LEACHING LINE [ ] No. of Lines --------------- Length of each line-------.---_---------------------------- Total Length ---------------------------- <br /> s <br /> 'D' Box.:-_-.------- Type Filter Material --------------------Depth Filter Material -------------------------------------_.._._. <br /> ' . "Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -__--__-_____-_---.-.-_- <br /> SEEPAGE PIT` [ ]f. �7y Depth _--r------------------- ,Diameter __w-_---------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> �. Vater Table Depth ------------------------------------------------Rock Size --------------------------------- <br /> Distance to nearest: Well_ _________________________ Foundation '________..____4-__ Prop. Line -_----____.-...__...-- � <br /> ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- -------------- ________________ Date --------------------------..-_____} <br /> Septic Tank (Specify Requirements) ____________________ ___--- -- <br /> Disposal Field (S cify Requiremen4!n" l Q F e �a�� _�^�t'iz <br /> �,. �'(4+4 �a- �e e 4 V- 1 _ to c *-------- <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: I <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 beco a su ject toyy Workman'sr,Compen sation laws of California." <br /> Signed VT-- - -- -- --- Owner <br /> By -----=------------------------------------- ----------------------------------------------------------- Title ------ -------- <br /> ----------------------------------- <br /> (If other than owner) <br /> AiRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _._-__-. _ ___. __ t --._ DATE <br /> --- - -- - -- - <br /> BUILDING PERMIT ISSUED ------------ - -------DATE --------------------- --------- --- <br /> ADDITIONALCOMMENTS ---------- --- ---- ----------------------- -- - ----------- ---------------------- ---------------------------------------------------------------------- <br /> t <br /> ---------------------------------------------------- - -------------- ------------------------------- -------------------------- ---------------------------------------------------------------------- <br /> ---------- <br /> Final Inspection by= ------------- -- ---- c -- -------------------------- Date <br /> ----- <br /> JI QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9, 1-'68 Rev. 5M , <br />