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FOR OFFICE USE: ` <br /> APPLICATION FOR SANITATION PERMIT- <br /> ri <br /> - --------------------------- Permit No. <br /> (Complete in Triplicate) <br /> ------ -------------------------------------------------- -- This'Permit Expires I Year From Date Issued <br /> - Date Issued _�A_: 4'.� <br /> Application is hereby made to the San Joaquin Local HealtgaDistricf for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> Q ---W__'-----IN_ ,S �j//V -/0IV----------------- --------CENSUS TRACT ..---------------------- <br /> JOB ADDRE55/LOCATION .___� _ __ _ _. - <br /> Owner's Name ------- -- ---------------------------------------------Phone / PJV-_P................ <br /> II <br /> Address �— <br /> �o�---� ��--- ��ll�_clu� _�r�---------------------------------- City --------- --�- -- - - <br /> Contractor's Name ---------, Pl (-- ------------------------------------------ License # ------ -------------- Phone _--_----------------__ <br /> Installation will serve: Residence Apartment Housef❑ Commercial ❑Trailer Court IEJ <br /> ' Motel ❑Other ----------------------------•-------------- �/! / / <br /> Number of living units:---1 Number of bedrooms ----/-----Garbage Grinder ____0--- Lot Size --l��_._./!__/--II--------------- <br /> Y ��r --------------Private ❑ <br /> Water Supply. Public System and name ___ _ <br /> Character of soil to a depth of 3 feet. Sand'❑ Si t❑ Clay E] Peat[:] Sandy Loam E] ClayLoam ;❑ <br /> 4_. ( 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.) s <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------_--------------- <br /> Capacity --------------------- Type -------------------- Material-------- :--- No. Compartments -----------:..-•-:---- <br /> Distance to nearest: Well ____________________________________Foundation ____________________ Prop. Line ___-_________:________ <br /> f <br /> LEACHING LINE [ ) No. of Lines ----_----_-------------- Length of each line-------------------.-------- Total Length ------------ ------------------ <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material --------------------._______________._.:.... <br /> Distance to nearest: Well ___________________ _`Faundation -------------------- Property Line ___________-______._.___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ------------ Number I------.-._._.-------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth -------------------------------------- -----.__Rock Size -------------------- <br /> Distance to nearest: Well ---------------------------------------Foundation -------------------- Prop. Line _-______--__________.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ______t-O�,,_-C------------------ Date <br /> _ Date _________________________________) <br /> Septic Tank (Specify Requirements) ---- f ' ` ____J__�tV/�------------ -----`--------------------- <br /> ---------- --- <br /> ° f ed¢ _�----_ �p� <br /> Disposal Field (Specify Requirements) --------�- ---- - - - f�-�-��-�°=�,--�----(__----�------------------------•------ - <br /> t •a <br /> ------------------------------------------------------------------------------------------------------------------------------------ ------------------------ ----------- ----------------------- <br /> 1 <br /> ---------------------------------------------------- ---------------------- - ---- ----- -----------------------:--------------------------------------------------------------- <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 /> li <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 /> By ------------------------------------------ ------------------------------------------------------------ Title ----------------------------------------- --------------- ------------ <br /> (If,other than owner) , <br /> F R.:DEP MENT USE ONLY <br /> APPLICATION ACCEPTED i3Y _________ _ _ ___ --------------------. DATE ------ __�_d_ .- ----------- <br /> BUILDING <br /> ---__ -- •- <br /> ----- ------ ----- - --------------------- <br /> BUILDING PERMIT ISSUEDBY <br /> ----- ---------- ------- --------------DATE ------- _ - <br /> ADDITIONAL COMMENTS -----------------------------------------------�------------ ---------------------------------------------------------- <br /> -------------------------------------------- ------- ---- -------------------- <br /> ------),-------- <br /> r 1 1 <br /> ----------------------------------------------- ----- -------------------------------------------------------------------- ------------ --r ------ <br /> Final Inspection by; ---------------- ---------------------------------------------------------------------------.Date ------- -== <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />