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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT <br /> --------------------------=------------------------------ QQ <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From Date Issued Hate Issued <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 .--l�t �__ / �=--- _ _ F.-{----).- CENSUS TRACT -------------------------- <br /> Owner's Name L �C�I/ �'- --t`----------------- <br /> ..- =�! ------- ------Phone <br /> Address ------------ �_ �'- �----- ---------------------------------------. City I --------------- ---- ------------------------•-•----- <br /> Contractor's Name --------- -t`-----------------------------License #1 _.-, _� - Phone ��--- -7e./' <br /> Installation will serve: Residence D6 Apartment House❑ Commercial:F]Trailer Court <br /> Motel ❑Other --------------------------- <br /> ---------------- <br /> Number of living units:--- Number of bedrooms ------Garbage Grinder / --- Lot Size - f E l _____________ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private. <br /> Character of soil to a depth of 3 feet: Sand'F]- Silt❑ Clay ❑ Peat❑ Sandy Loam D< Clay Loam <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,] l <br /> PACKAGE TREATMENT [ SEPTIC TANK:A Size__//. 11?X_4------- ____ Liquid Depth ------------- <br /> Capacity <br /> ____---_--Ca acitY ------ No. Compartments --..... ......... N.12TYPeMaterial <br /> Distance to nearest: Well / � _�________________Foundation Z��-/____.__ Prop. Line __�_�-�__--------- <br /> .. <br /> LEACHING LINE No. of Lines -- -_______________ Length of each line---��_______--- ------ Total Length ------------ <br /> 'D' Box yC - _ Type Filter Material z-- Depth Filter Material ��`,_______-----------_----------- <br /> bistance=to nearest:-Well _f! ____________ >oundation __ '___._____-_- Property .Line ___sem_.___.____._._._ 1 <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ----------------- ---------- Rock Filled Yes ❑ No ,0 r <br /> Water Table Depth ------------------------------------------------Rock Sze -------------------------------- ` <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _------_------------------------------------ Date ----------------------------------) <br /> SepticTank,(Specify Requirements) ------------------------------------------------------ --------------------------------------.-----------------!----------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------ ------------------------------------------------------------------------ ------------------ <br /> --------------- -------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- <br /> ----------------------------- -- <br /> --- d -------------------------------------------------------------------------------------------- <br /> » (Draw existingand required a <br /> q addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work w111WTe done..in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and-iegulations of the San Joaquin Local Health District. Horne 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 i <br /> B Title , <br /> -- - -- - ---------------------------- <br /> (E her than owne <br /> _ FOR -DEPARTMENJ UR ONL <br /> APPLICATION ACCEPTED BY ----------------------------------- = ---------- DATE - s -1-�I�9------ <br /> BUILDING PERMIT ISSUED ------- ----------------- --------- -- - -------DATE ---I-------------- <br /> --- ----------------------- - ------ - -------------- <br /> ADDITIONALCOMMENTS ------ ------------------------------------------------------------------------------- ------------------------ -------------=-------- ------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------- -------------- --------------------------------------------------------- <br /> - ---------------------- ------- <br /> Final Inspection by Date <br /> SAN JOAQUIN LOCAL EALTH DI RI <br /> E. H. 9 1-'68 Rev. 5M. <br />