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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ....................1�............. .`�.3..-�. : <br /> iComplete in Triplicate) �r Permit No: <br /> This Permit Expires 1 Year From Dante Issued Date Issued <br /> ...........I--- -- -------- <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 /> egulations:JOB ADDRE55/LOCATEON ... cc .:_, ...... Q1 ...CENSUS TRACT . <br /> Owner's Name .... ..-•----. --• ---------Phone •--.... _.. ............. .�..... ........ ..... <br /> Address _ .•-•............ <br /> '► 4VZle7? ...................................................... ......••--..... City . �,i !.. _ <br /> Contractor's Name - <br /> '` ,P .... <br /> Installation will serve: Residence []Apartment House Commercial jETraller Court fl <br /> -Motel [3 Other...............I............................ <br /> Number of living units:......... Number of bedrooms.... '...Garbage Grinder Lot Size ..:............. <br /> Water Supply: Public System and name .................................................---------...................•--•..............................Private {� <br /> Character of soil to a depth of 3 feet: Sand I-] Silt❑ -Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ e <br /> Hardpan ❑ Adobe Fill Materiat ............ If yes,type .................::... .... <br /> (Plot plan, showing size of lot, location of system .En 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 TREATME=NT [ ] SEPTIC TANK% Size..IKX.�XX._..... ... Liquid Depth .lI......_._.-:,•--•_ <br /> Capacity I;W.a....... Type� ice. Material Ce_&ee'..... No. Compartments _ <br /> Distance to nearest: Well .. /. .......................Foundation . ......... Prop. LinV4`1 7............ <br /> LEACHING LINE dQ No. of Lines ...../............... Length of each line.Z a ........... Total Length ,AA ................ <br /> 'D' Box ,/dle.. Type Filter Material 14- Depth Filter Material _��_._..._f........:................. <br /> fii <br /> Distance to neatest: Well ..../.lam_....... Foundation ... - Property Llne <br /> 10 `,f..1:.........:. <br /> SEEPAGE PIT Depth -_.a L T�4... _. Diameter U...... Number _.._.. ................. Rock Filled Yes a No ❑ <br /> Water Table Depth Rock Size <br /> ................... <br /> ---- ._....... <br /> Distance to nearest. Well _..____.f4�� ...................Foundation ... .... Prop. Line _, �....... <br /> R PAIRJADDITION(Prev. Sanitation Permit# ..... .................................. Date ---------------------------------- <br /> • . 1 <br /> Septic Tank (Specify Requirements) ✓w' <br /> _/ ---•-•••...................•---•--•-•----•--•--•--............................._......_....-••-•-...... <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." t' . <br /> I Signed ............ ..... ...•------ ,Own <br /> er <br /> By. _. Title _ <br /> (If ee than owner) <br /> FOR DEPARTMENT, 6SE ONLY <br /> APPLICATION,ACCEPTEDBY ........... .............. .�"" ` ....................................... DATE ...... ............... <br /> BUILDING PERMIT ISSUED =- ---.....-••••••••• <br /> ------••••-• ...........................................:.............•-••........... -._DATE ... .... <br /> ADDITIONAL COMMENTS ................. <br /> l •---•----••----•-•-•-•-•-•----------••...................................•--••-•----------••••----.._.... .... . ...... ............................................................--- -- <br /> ! .......................... ---....__........ ...............:.:. ........................ ..................... ... ........................._..._........... <br /> I .............................................. ... . ........... .................................................................................• ........ „ . .. . <br /> _/.,Final Inspection by: ... ... .. . . ..... ......................................... ....Dae .._ .._ <br /> SAN JOAQUIN:LOCAL.'.-HEALTH DISTRICT _ <br /> 7.3 24 7/723 M <br /> E. H. 1.'68 Rev. 5M - - - <br />