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FOR OFFICE USE:,. APPLICATION FOR SANITATION PERMIT <br /> {Complete in Triplicate} Permit No. ./7 ---- --� <br /> ----_____------- This Permit Expires 1 Year From Date Issued Date Issued 1t1-- -- j <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 <br /> ADDRESS/LOCATION <br /> --O--N� <br /> - �-- --- Yr��-- --�er <br /> '�-------- - ---..CENSUS TRACT -------------------------- <br /> ' <br /> Owers Name ...�-------� '/7--�-0 �------ ------------ ------------------------- } --------------Phone .-------------- <br /> ------------------- <br /> Address ' <br /> ------ "-�-f�- -�'---=- ' -------------------------- - - --------------------. City 'zae— -- ------------------------------------------- <br /> Contractor's <br /> ---------- --- -------------------------Contractor's Name ------- , 7f1, la. --------------------------- License #14012.lpz�- Phone <br /> Installation will serve: Residence(Apartment House❑ Commercial:❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> r � <br /> Number of living units:---- ----- Number of bedrooms .--2----Garbage Grinder*b9-.- Lot Size p-- ------- !__'Q-------- <br /> Water Supply: Public System and name ---C-I4L --•,- , lt?- G ---. Q --s-------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 <br /> I <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,] "1! <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity---------------------- <br /> _-____-__---_--_---._-.Capacity,--'------------------ Type -------------------- Material----------- - -------- No. Compartments ------•--•---..-. <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---.------ .:-.....-_ <br /> LEACHING LINE [ ] No. of Lines ------------- - Length of each line---------------------------- Total Length ------------- <br /> ------------ <br /> --_ # <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------'----- <br /> --------------- <br /> ,< Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --------------------.--- <br /> SEEPAGE PIT [ ]. Depth -------------------- Diameter ---------------- Number _____.-.--.--.-.---- ---- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth <br /> ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------_.---- Prop. Line --------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) 1 <br /> Septic Tank_(Specify Requirements] ---------------- ------------------------------------------- -- -- <br /> Disposal 'Field (Specify Requirements) <br /> • <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 /> 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 ----- ---------------------------- - �i' ------------------ Title ----- <br /> (If other owner) <br /> Ef ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -- - - ----------- --------------------------------------------- DATE -IST ' = O -------- ------ --- <br /> BUILDING PERMIT ISSUED - ----- -- ---------------------------DATE ------------------------------------------- <br /> --=-- - -------- ---------------------------------- <br /> ADDITIONALCOMMENTS ------- - - -- ----------- ------ - ----------------•------------------------------------------------------------------------------------------------- <br /> 40 - - .--- ------ -- --------------------------------------------------- ------- -------------------------------- ----------- ---- --- ------- <br /> -------- ------------- - - ----- - <br /> - -- -------------------------------------------------------- ----- --------------- ------------ - - -- ----- ---- - <br /> Final Inspection by: ----- ---- --- ---------------------- Date ls� 0 <br /> -- --- - ------------------------------- 1T I -- - -- ----------- - ------- <br /> SAN'JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />