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' FOR OFFICE USE: <br /> J ,PPLICATION FOR SANITATION PER` <br /> .---- <br /> Permit No. i✓- 5 <br /> (Complete in Triplicate) <br /> Date Issued --- _-----. <br /> ____________________________ -_______--------------- <br /> This Permit Expires 1 Year From Date Issued <br /> _ <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. 349 and existing Rule and Regulations: <br /> r <br /> I JOB ADDRESS/LOCA N -- -- ----- - ----------------- ---��-►�-�o�__------CENSUS TRACT ---------------.---------- <br /> L Owner's Name --------- - ---------- ----- -- ----- ---------- - -------- :.. ---------- -------Phone ------------------------------------ <br /> Address � <br /> - a1_q_-�r-- --- --- -- ---- F ------- City ---- ----------------•---------- ------ <br /> Contractor's Name r I � -------'•----------License # _� _ __ Phone --------------------_ ....... <br /> C <br /> i L <br /> Installation will serve. Residence ❑Apartment House Commercial ❑Trailer Court ❑ <br /> Motel F1 Other ---_-_` <br /> Number of living units:---I------- 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.0- <br /> Hardpan ❑ Adobe ❑ 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 /> s <br /> PACKAGE TREATMENT [ SEPTIC J1 Size_V "-_-_�_-I_-f__--'- -4 ..- -- Liquid Depth ---q-____-_-.__- <br /> C, . <br /> I Capacity Type L"�^- "-�--__ Material--_re--- --------- No. Compartmerits ----- ------------ <br /> Distance to nearest: Well ---------!a__--.................Foundation -_-�-�_--_-_---__--_ Prop. Line <br /> LEACHING LINE [ j No. of Lines --------(------------- Length of each line---------- _ _- ---------- Total Length _--to-o-------------- <br /> i 'D' Box ------------ Type Filter Material -------Depth Filter Material ------If_-------•--------------...------- <br /> L Distance to nearest; Well __-__5-a-f_-_----- Foundation <br /> + Q Property Line. ----C-.- <br /> � " <br /> _ SEEPAGE PIT [� Depth -------a"Z-�_-_ Diameter ________-------- Number -------�___-_.------------ Rock Filled Yes � No .i❑ <br /> I e� <br /> ` __//,6 <br /> L '- '------ <br /> Water Table Depth _---_.-___7�--------------- ..-__Rock Size _- / ---__-_- <br /> k <br /> Distance to nearest: Well ---------- - -Q.f------------------Foundation --------- S <br /> -- -.�.. Prop. Line ....- _._.--_--_-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------...._..__---__---.------_) <br /> 4 <br /> Septic Tank (Specify Requirements) ------- ------ ---------------------------------------------------"�---------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> L -------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------w------------------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- <br /> r (Draw existing and required addition on reverse side) <br /> i L 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 /> I sed agents signature certifies the following: <br /> N "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 /> L} as to become subject to Workman's.C ensati,on laws of California." <br /> Signed -------------------------------------CA�_ <br /> ------ - --- Ownes , <br /> �� <br /> "" �°L <br /> BY ---- --------------------------------------- =---- --- - -` --- Title -----•(If other than ow <br /> R DfpARTMENT USE ONLY <br /> LAPPLICATION ACCEPTED BY w _C ---- - -----------------------------------------------------------. DATE ----------------- <br /> BUILDINGPERMIT ISSUED -- --------------------------------------------------------------•------------------------ -------DATE ------------------------------------------- <br /> t. ADDITIONAL COMMENTS ----------------------- --------------------------- <br /> ------------------------------------------------------------------------------------------ --------------- <br /> L ------------------------------------- <br /> --------- <br /> ----------------------------------- ------------------ - _ __ -----------------------: ------ ---------------- ------------- -------------------------- ' <br /> �' --------- --------------------------------------------------------- - <br /> Inspection by: -- _---_Date <br /> K `---- --------- <br /> Final f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I L <br /> 1 <br /> E. H. 9 1-'68 Rev. 5M <br />