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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. -_7_2-_ __ L Z <br /> - (Complete in Triplicate) <br /> - - This Permit Expires 1 Year From Date issued <br /> Date Issued <br /> ------------------ ---------------------- --------------- <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. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA ION .--- --- -- ---- _. ---- - ----C�54:.__----f_`.- --_=-__--CENSUS TRACT -------------- ----------- <br /> ---Phone Name ._- - _ ' 14,4-- __� Phone _- 7q�4 <br /> A-M- `5 = - <br /> Address ----------- ---- e -----------------=---. City-----M:1S R -C A, <br /> _ <br /> Contractor's Name ---.___-- -- -�V_ "--------•----------License # 1p��U--- Phone 4_�L2_3_�3-.�- <br /> N, , i <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:C-/) Number of bedrooms0)----Garbage Grinder -------- ._ Lot Size <br /> Water Supply: Public System and name -------------------------------•-------------- h Private <br /> Character of soil to a depth of 3 feet. San�d� Silt❑ Clay ❑ Peat❑ Sandy Loam ,E] Clay Loam <br /> Hardpan ❑ Adobe 'D k Fill Material ------------ If yes, type ---------------------------- <br /> e <br /> (Plot plan, showing size of lot, location of system-in relation-to�,wells,buildings,, tc. must be 'placed on reverse side.) <br /> NEW INSTALLATION: fNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> i it <br /> PACKAGE TREATMENT [ IJI SEPTIC TANK>< Sized , _�--�------------------- Liq depth _6 -------­------- <br /> Capacity _t00--- -- Type Material_04_� �No. Compartments ------------ V <br /> Distance to nearest:lWelf -- _-_------------------Foundation -------------- Prop. Line _ _____________ tni <br /> LEACHING LINE X No. of Lines _ _� <br /> Length•of each line--_ .Q ________________ Total Lengfih -Q_.__-._______.__-- <br /> I .- , rf <br /> D' Box( Type. Filter Material fpGK;______Depth Filter Material _ __ _______-_--__--.�-' <br /> '`-- �Q---------------- Property Line Zo <br /> Distarice'to"nearest?`Well __��_______________Foundation __,__ <br /> SEEPAGE PIT [ ] Depth t <br /> ______.--_________ Diameter ________________ Number .__._�____________.______ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth r ---Rock Size <br /> Distance to nearest: Well --------------_______-----------------Foundation __________________ Prop. Line --______-_________-__ <br /> REPAIR ADDITION(Prev. Sanitation Permit# ___________---______'-__ ----------------- Date _______'__________________________) <br /> Ji <br /> Septic Tank (Specify Requirements) -----.--- - •5 ----_��_ 14A &Z_-0_-)---- ---- -. „0M------------------- <br /> Disposal Field (Specify Requirements) ---------------------------------------t---- ----------------------)--------------------------------------------------- --•------------ <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 b me su I t to Workman's Compensation laws of California." <br /> Signed - - � -----. Owner <br /> By ------- "tC ------� ------ --- ---' ,% Title ------- ------------------------------------------- <br /> (If of er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- -=-- ----`-- _ _ - ------------_---. DATE _(_5 - _ ----------------------- <br /> BUILDING PERMIT ISSUED ------------------------- - -_DATE ---------------_----_ <br /> ADDITIONALCOMMENTS - -------------------------------------------------------------------------------------------------------------- ---------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------I---- ---------------------------------------------------- <br /> --- ----------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------- --------------- <br /> -------------------------------------------- <br /> -------------- <br /> ------------------------------------------- ---- = j --I------- <br /> Final Inspection by: ---------------�----��----- ----------- ------------------------------ - - --- --- --- -----------.Date -`� J-�Z-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'68 Rev. 5M <br />