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( c , Z <br /> � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> t -------- -----------------�--------- Permit No: <br /> (Complete in Triplicate) <br /> --------=---------- - -- <br /> -------------- ------------ <br /> Date Issued <br /> This Permit Expires ] Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance <br /> /with <br /> hCCounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._r�(�-��__l�_---_U --------C.'-11&wl------ ------------- ----CENSUS TRACT -------------------- <br /> Owner's Name -Pezv4d rao----Re-e`A1"_AV1&X1--- li�!�------------- ------------ Phone-------------------------- --------- <br /> Address ---------------------- -------------------- ------------------------•--. City ' <br /> Contractor's Name -- �<C _=__--- - &�C --------------------------------License # oft+ � ---- Phone - � 7f4 <br /> Installation will serve: Residence ❑Apartment House,Commercial ❑Trailer Court 0 <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------------ Number of bedrooms __________Garbage Grinder ____-___-- Lot Size ------------------- <br /> --------------------- <br /> Water Supply: Public System and name -----------------------------------------------------------------------------------------------------•---------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand X Silt❑ Clay' ❑' Peat❑ ' 'Sandy-Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe (] FiIT Material ------------ If yes,type --- ------------------------ <br /> j <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_.._� _ _ }C_�___------_.- Liquid Depth ___'z_ --________-- Q <br /> Capacity Type P/Z-e- S�M.aterial---------------------- No. Compartments -- ----- --_---- <br /> Distance to nearest: Well ________ _ __________________Foundation -----1_ ____:_____ Prop., ine ----- <br /> LEACHING <br /> ___LEACHING LINE [ ] No. of Lines ------/---------------- Length of each line_' Y__ ______ Tota I9..Length ______ ----------- <br /> 'D' Box ---- Type Filter Materialpth Filter Material- __--_ _______ -------------------- C <br /> Distance to nearest: Well __:___________________ Foundation ____------------------- Property Line. ----------------------- <br /> SEEPAGE PIT [ ] Depth _________________ __ Diameter ---------------- Number ___+__-_-________------__-__ Rock Filled Yes ❑ No 0 <br /> Water Table Depth i ----- ---------------- -------------- ----=--Rock'Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ­_---------------------------------------- Date -----------------------------------1 <br /> Septic Tank (Specify Requirements] ------W------------------------ ------------------------------------"----:---------------------------- ----- , -------------------------- <br /> Disposal Field (Specify Requirements) ___ -----------_--------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- ------------------------ <br /> --------------------------- ---------------------------- ------------ <br /> ---------------------------------------------------------------------------------- ---------------------------------------------- ---------------------------------------------------------------- <br /> i (Draw existing and required addition on reverse side) <br /> i 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 <br /> licen-sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, T shall not employ any person in such manner <br /> as to become subjec to W rkman's Compensation laws of California." <br /> Signed _.- - - -- r --��T1,.1� -�t�----------------------------------- Owner <br /> --- -------------------------- ---------------------- Title _ -_ <br /> (If other than owner) <br /> € - FOR .DEPAItTMENT�US ONLY <br /> APPLICATION ACCEPTED BY ------------------------- --------------------------- <br /> - ---- -------- -------------------- - ---. DATE ---- ----------- ---------------------- <br /> I BUILDING PERMIT ISSUED ----------------------------------- DATE -------------•------------------ ---------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------- --------------------------=------------------------------------------=-------- - <br /> -------------------------------------------------------------------------------------------------- ------------------- <br /> ---- <br /> I Final Inspection by: --------------------------------------------------------------_-- -- - - --- --- ---------------Date coli <br /> k SAN JOAQUIN, LOC, L ALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M �,� <br />