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FOR OFFICE USE: <br /> -------------- APPLICATION FOR SANITATION PE Permit <br /> ----------------------- - ----- ?ermit No: <br /> (Complete in Triplicate) <br /> --------------------------- ---------------- ------ <br /> __..----------------- ` This Permit Expires 1 Year From Date Issu t sued <br /> Application is hereby made to the San Joaquin Local Health District for a permitWtons ct and ins all the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ...--- 11 -71------,f __t�-J --1."" ---------------------- CENSUS TRACT ---- <br /> M Owners Name .-`����.---- � -' <br /> ^� i' Phone <br /> l` <br /> Address --------�-�-�� --- -�=--�`' k�-`--)-'_----------------------------------- --- - ----- Ci#Y -------�2-fir'� [`���--��-------------------------------------- <br /> Contractor's --------- License --Y---- Phone <br /> Installation will serve: Residence,n Apartment House❑ Commercial [7]Troller Court <br /> Motel 0 Other -------------------------------------------- <br /> Number of living units:-----/_---- Number of bedrooms ---3•-----Garbage Grinder ----- Lot Size ----- .`. =`.ALJ <br /> Water Supply: Public System and name ------:-- ----------------------------------------------------------------------------------------------------Private.t . <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe .5;k 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK!( Size.----------------------------------------------- Liquid Depth ------------.-.--.--,----- <br /> Capacity -------------------- Type -------------------- Material----- --------- No. Compartments <br /> i <br /> Distance to nearest: Well ---------------------------------- - <br /> Foundation ----.-----.-------.--- Prop, Line ----------------------- <br /> � <br /> LEACHING LINE [ No, of Lines -------.- ___� ___-.____. -Length of each line------efVe Total Length ;.--�C..1.---._-_-.-- <br /> 'D' Box f------ Type Filter Material ----- -Depth Filter Material -------- _- <br /> " Distance to nearest: Well -_.-. `- '_r_-.-,Foundation -------------- <br /> Property Line 45--------------- <br /> SEEPAGE PIT. ' Depth ..- ------- Diameter Number ----.-../----------------Rock Filled Yes No ❑ <br /> Water Table Depth ---- C----------------- -------Rock Size ----------- ----_-- - --- <br /> _ ---- <br /> Distance to nearest: Well ------ZZ: '-------------------_-Foundation ----__Z-!...... Prop. Line ----- ....... <br /> REPAIR TION rev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> -----.----._-- _--_-__-___-_-_-_Se tic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) - -, _--.. - _a �=------------------.---_----.- <br /> ----------------------- ---------------------------------------------------------------- - <br /> ---------------------------- ---------------------- ------------------------- - --- -- ---------------------------------------------------------------------------------------------- <br /> a (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: <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 /> _ V <br /> BY w <br /> --------------- ---------------- Title <br /> (If other,than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------- --- ----------------------- <br /> -----. DATE -- /w--- --.---/------------------- <br /> BUILDING PERMIT ISSUED ----------------- -------DATE ----------------------------------:-------- <br /> ADDITIONAL <br /> -- ------- COMMENTS -------- =Lj----------------------•----------- - ------------------------------------------- <br /> ----------- ------ -=-- ---------------------------- t - -- - ------------------------- ------------------------------------------------------------------------------- ---- - -- <br /> - ------- <br /> ------­--------------- <br /> ------ <br /> ------- ----------- = : --- --- --- <br /> ------------------ ---- ----------------------------------------------------------/ - - <br /> Final Inspection bY-r' Date .------------ --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />