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e FOR OFFICE USE: <br /> 1a E APPLICATION FOR SANITATION PERMIT <br /> (Complete in.,Triplicate) Permit No _�L-_�07_- <br /> ----------------------------------- _ <br /> --------------- This Permit Expires'l Year From Date Issued Date 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 <br /> -------------------------- - ----CENSUS TRACT <br /> I Owner's Name �X( �-- I{ -- : <br /> ------ ----------- <br /> s <br /> Phone <br /> Address --------------- ----_. Cityf-�G /� �? ______ ' <br /> Contractor's Name ._. ___ -a. 4O-11 .r '- <br /> Vt--------- --------=-------.License # � _ Phone <br /> Installation will serve:, Residence JKApartment House ❑ Commercial'❑Trailer Court ;❑ <br /> Motel ❑ Other ----------- <br /> f <br /> Number of living unit_ - �_ mber of bedrooms ______Garbage Gr�inde!/ ___ Lot SizefX .� <br /> Water Supply: Public System and name _________ _ __ __ _ ____ � •- - " . Private <br /> - -------------------------------------------•- <br /> Character of soil to a depth'of 3-feet., Sand'❑ Silt❑ Clay ❑ Pe E] Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ' Fill Material ------------ If yes, type ---------___________________ <br /> (Plot plan, showing siz4of lot, location of system,in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic itank or seepage pit p re mittecl'if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT, [ ] SEPTIC TANK[ l Size : ________________________ __ <br /> Liquid Depth -----------------•-------- Q <br /> Type -------------------- Material---------------------- No. Compartments ------•------- <br /> f <br /> Ccipacity'dDistance-to nearest: Well, _________________________-\------Foundation ---------------------- Prop. Line --..-.--------•---•--- <br /> LEACHING LINE [)+i, No. of Line#st __________- w <br /> ------ Length of each line--------------------- ------ Total Lengthi <br /> k - 'D' Box -.---------- Type Filter3.MateriaE --------------- ^ti's•.• <br /> ----Depth Filter Material ------ -------- ---=-----------•---•------- ] <br /> 1 - 1 <br /> Distance,to nearest: Wel! -----------------------.'rFoundation ___._____--______--- Property 'Line '-----•----------.----- <br /> SEEPAGEiPIT [ ] Depth +- "_�.---__ `- Diameter _______________ Number "_. _771_- Rock Filied Yes ❑ No I❑ <br /> I .Ir. } <br /> Water Table Depth ----------------------------------� Rock Size --------------------------- <br /> -----------­ <br /> I <br /> + ---------- ' <br /> „ Distance to;nearest; Well ._______________________l_ __ _ ` <br /> ' ------.Foundation ---------- Prop. Line <br /> REPAIR/ADDITION(Prev.�5anitation Permit�# ------------------- <br /> ------------------------- Date ------------------ <br /> i <br /> Septic Tank (Specify Requirements) - f <br /> -- I -; - <br /> r <br /> Disposal Field (Specify Requirements) _- --------- ' ----- - f ,� <br /> -- - <br /> - ed J--------------- ----------------- --------------- <br /> hereby certify t at I have preparthis application and that t <br /> (Draw existing '-------------------------------------- <br /> ".----------.------ -----.-------and required addition on reverse side) . •— - - <br /> he work will be done in accordance with,San Joaquin <br /> County Ordinancesr State Laws, and Rules and Reg ula0ons"oi 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, 1 shall not employ any person in such manner <br /> as to become subitct to Workman's Compensation laws of California. <br /> Signed ---------------------- ----------------- <br /> --------------------------- <br /> - - <br /> r <br /> -------- ----------- ------ <br /> Owner <br /> B ---------- - Title <br /> (If of than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 'APPLICATION ACCEPTED BY �-- _ <br /> --------------------------- --"---------------------. DATE _1L <br /> -40ILDING PERMIT ISSUED -------------="------------- --DATE _.. <br /> ----------------------------------------------------------------- -------------------------------------- <br /> ADDITIONAL COMMENTS ------------ !__------------ <br /> ------------------------------------------------------------------ -- <br /> ----- --------------------- <br /> - -------------------------------------------------------------- ---- -------- ----------------------------------------------------------- <br /> ----------------------------------------------- <br /> Final <br /> ------------------------------------ -- �-- <br /> -iria Inspection by pate ...... <br /> 5AN JO QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />