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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ilii Permit No. -7V-J----3 <br /> ICompete in Triplicate} . <br /> This Permit Expires 1 Year From Date Issued Date Issued __ ----------2o <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 /> JOB ADDRESS/LOCATION ___.- _ �' ' '` __+��_ __-____ __ CENSUS TRACT. �_qD____----------- <br /> Z <br /> _______ _ <br /> / --------- - <br /> Owner's Name t2• `� -h"_ -----------------•------------•----------- --------------------------------------Phone -------------------------------- <br /> Address ------------------------------------------------------------ --------------------- itY ------------------------------------------------._..._..--•................ <br /> '�._ <br /> Contractor's N�e �+'-r ��_�_--------------�Q'--�'�---���----=--- ---.,r1ce # ----- .-- ---------- Phone ------------------------•--•-- <br /> Installation will serve: Residence Apartment House❑ Commercial[]Trailer Court ❑ <br /> Motel ❑Other ----------------------------------------•--- <br /> Number of living units:_'_________ Number of bedrooms __3__.._--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 <br /> .. v_r _. <br /> Hardpan ❑ Adobe .k Fill Material_:_-_.______ If yes,type----------------------------- <br /> I <br /> f - <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,) b� <br /> PACKAGE TREATMENT [ j SEPTIC TANK'41 Size__'t_`7t__/_-�"______________________ Liquid Depth ---1�'�_____--____-- <br /> Capacity i1ye-V--------- Type Material_A! ----------- No. Compartments y.....:.......... <br /> Distance to nearest: Well ____ _____________________Foundation __/_o_r____________ Prop. Line -----Z. <br /> LEACHING LINE: j No. of Lines ----3----------------- Length of each line-------g0--------------- Total Length ._ __•__________- <br /> 'D' Box ------ Type Filter Material Depth Filter Material _ -�LF--------- <br /> Distance to nearest: Well _____________ Foundation -/-.Q..... Property Line <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ________________ Number ---------------------------- Rock Filled Yes [] No 0' _ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> ----------------------- -Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ____.--_--________--_. . <br /> ---------1 ' <br /> REPAIR./ADDITION(Prev. Sanitation Permit# ..___...-________________________________ Date ---------------------------------- <br /> Septic <br /> ......__. _ �<_ <br /> Septic Tank (Specify Requirements) -- ------------ --- ------- ------------------- ------------------------•- -Y. <br /> ------------- ---------------------------------------------- <br /> DisposalField {Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------- ------------------------------------------------------------ -------------------------------------------------------------------------------------------------�----------------------- <br /> -------------- --------. -: --------- --------- - - -------------- a <br /> '(Dravw 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 borne to Workman' _ o p nsati.on laws of California." <br /> Si ne --- . <br /> 9 -------------- Owner <br /> BY ----------------------------- -- --------- ----------------------------------------- -Title --------- ------------- <br /> ----------------------------------------------- <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _- A;&O&--------------------------------------------------------------- <br /> DATE _ ?�?--------------------- <br /> BUILDING PERMIT ISSUED _______________________ _DATE ____-_______.______-._ <br /> -------------------------------------------- --------- - --� ------------ ------------...----- <br /> ADDITIONAL COM%_NTS _ ____________ ___ <br /> = ' -------- a ------------------- -------------------------- <br /> -------------------------------------- ---- - --------- ----- --- ----- - ----------------------------------------- <br /> - - - - - - - -- <br /> ------------------------------ --------- ---- ---- -- ---- ---- --- ---------- - <br /> Final Inspection by ----------- ---------------------Dote '"" ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />