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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> '-� / <br /> - - -------,•------ -------"� Permit No: <br /> (Complete in Triplicate) <br /> it <br /> This Permit Expires 1 Year From Date Issued <br /> � � Date Issued <br /> _ _ _ <br /> ------ ----------- - ------------------------------ <br /> Application is hereby made to the San-Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance ith County rdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __-_.-CENSUS TRACT -------------------------- <br /> Owner's Name -------------------- "-- ----------- -------------------- -------- -------Phone d �� <br /> Address -------------------= ---------------------- City -----------------------------------•------- <br /> -- - <br /> Contractor's Name - - ---- ----- ----- ----�,,, -----------N-----=--=-- License # ------------------------- Phone <br /> Installation will serve:. �� Residence)dApartfnent Hoe-❑ornNmercial ❑Trailer Court ❑ <br /> ;i <br /> Motel ❑Other ----------------------------------------- •- <br /> Number ofliving units:___._._-- Number of bedrooms ----�.G ba_ge Grin -- Lot Size ---410 x'__4"2^0______________. <br /> u ` <br /> Water SuPPIY Public System and name..=-— .. `1K'�'5r--------- --_ -- _-- = Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt fl Clay o, fig❑ Sandy Loam Clay Loam,0 <br /> Hardpan 0 Alobe Fi1�1-Materinl�----____-- If yes,type----------------------------- <br /> (Plot plan, showing size.of'ilot, location of s stem in relation to wells, buildings, .etc. must be placed on reverse side.) <br /> NEW INSTALLATION: . (No septic tank or se page pit permitted if public sewer available within 200 feet,) <br /> PACKAGE TR%TMENT I ] ASEPTIC TANK:[ ] Size----- !`a=--------------------------- Liquid .Depth ------------------------ <br /> R. --------------- <br /> -----------------------.' CapdcitY ---- Tye ----- <br /> e <br /> Ma rial ----- I No. Compartments <br /> l. <br /> • • Distance to nearest: Well--------------'---_------------`___--}F.oundation ---------------------- Prop. Line ----------------_-•--- ; <br /> 0 . <br /> LEACHING LINE [ ] No. '`of Lines --------------------- -- Length' of each 'line -------- ------ Total Length -----------­___..--.-..---- <br /> I I l <br /> D' Box ----___- - 7�`e Fil;fPlber Material -------------r <br /> Distance to nearest: Wel I --- <br /> --- ------------- Foundot� -_ -----• Property Line ___________-_____.._.___ <br /> SEEPAGE PIT [ ] Depth ___-___-_��______--- Diameter/---- ��Nvmbe� _____�i�____---_ Rock Filled Yes ❑ No , <br /> Water Table Depth -----------,' ---------- ----------------------Rock Size ---------------- --------------- <br /> Distance <br /> ----- -----Distance to nearest: Well -------__-_--_____________----------_Foundation ------- Prop. Line ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -•---1-•------------------------------------ Date -------------------_-_-- <br /> Septic Tank (Specify Requirements) ----------------- ------------------------------------------ - ..-------------------- --•--- <br /> �i t .. <br /> Disposal Field (Specify Requirements)_ �'__e__� --- - f,-- <br /> - ---- ---- --------- -- - - - <br /> . I - L--------1 <br /> . . s- ----- --- w <br /> --------------------- <br /> ---------- <br /> I hereby certif that I have--re bred [cation and that th-- w <br /> e ��V raw existing and required addition on reverse side) <br /> y y' 'prep � � pp a 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 signaturece t files thePfollowing:4 <br /> "I certify that in the performanmil f he work for which this_permet is_issued, l„shall.nct employ any person in such manner i - <br /> as to become subject to Workman's Compti nsation laNvs�of California." <br /> Signed - - -- -- ---- - --- --- ' T Owner <br /> BY r #----------------- Title ------- vel <br /> f other an owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION AC PTED BY--- --------------------- --=�------- L-- --------------- DATE �Y--------------------- <br /> BUILDING PERMIT ISSUED __1----------------------- 4 DATE ' <br /> ADDITIONAL COMMENTS ------ � `'^ = -A ---------------- M <br /> r <br /> - -------------- <br /> mtf-�-�-f-q_ - <br /> ----- - ---- Y= -------------- ----------------- ----------- --------------------------------------------------- <br /> Final Inspection b ----------------- C s} i� ----------------•------------- - Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s� <br /> E. H. 9 1-'68 Rev. 5M <br />