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I I 1 <br /> 'r <br /> FOR OFFICE USE: , ' APPLICATION FOR SANITATION PERMIT <br /> ' --------------------------- Permit No. -- --------------- <br /> ' - --------------------- -- --------------- ilIIComplete in Triplicate} <br /> --------------- ----------------------------------------- 3a 7 3 <br /> Date Issued <br /> ----------_-_------------------------- . ___- /� This Permit Expires 1 Year From Date Issued <br /> Application is herebymade 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 o. 549 and existing Rules and Regulations: <br /> �X <br /> !�I ---- ----CENSUS TRACT _---y ---•----------- <br />' JOB ADDRESS/LOCATION :-r.�e�---��� -f--.-----[�.-���I�a�- ------------ <br /> Owner s Name ._ ------11 Phone <br /> ----- , P- /7---- .. � <br /> I Address -----/--�� �: - ------- -- - �`'�___ ---� -- ----------- City �� <br /> i <br /> /' -- -- <br /> Contractor's Name .__ _� --- r � License #©2�l Pho,e 3 __;e4 <br /> Installation will serve: Residence Apart.n)ent House❑ Commercial :❑Trailer Court .'❑ <br /> Motel ❑ Other - -------- -------------------- i <br /> :may ,,,-- i <br /> / .�° ,�i� ------------- <br /> Number of living units______ _____ Number of bedrooms ____-, _=___Garbage Grinder/� ... Lot Size _ __. <br /> �� tG rA -___Private <br /> Water Supply: Public System and name ---------------------------------I------------- = ... <br /> Character of soil to a dept) of 3 feet: Sand❑ Silt❑ Clay ❑ Peat E]---,Sandy Loam -❑ Clay-Loam,5 <br /> T Hardpan ' Adobe ❑ Fill Material ----- ------ If-yes—, type-—-------- ---✓-------- -- "` <br /> it , .: ; ,, � <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be p.la�ed o,f verse side.) V <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,). <br /> PACKAGE TREATMENT {��] SEPTIC TANK V Size---- -% --�----------------------- Liqui Depth ------------:----- <br /> acit 12499P--•- T e�- / *- Compartments' 2 .............. W <br /> ! CI i �� # <br /> Di P nce to nearest: Wel � "� Material <br /> -- --No_�Co__ Prop. Line ---�---_._____-- <br /> LEACHING LINE N�o. of Lines<- _____ —___------ %Length of each line_-__ �-�- Total .Length : f 10FI&- ------------ <br /> --------- <br /> ----------- e <br /> 6' Box �' - Type Filter Material`j�� Depth ,FilterrNCater�al .,-----•,-- -----••-•-----------•- <br /> Avg <br /> ;jitil <br /> bistanc to nearest: Well ___ ---_________ Foundation' .__/a----�- -■Property Line. __s'�"_�___............ <br /> �i�, gg e �� <br /> SEEPAGE PIT Depth --c�-�-=-____ Diameter , s -- Number.,_=___---------------- Rock Filled Yes No i❑ <br /> II if �' <br /> Water Table Depth -------- --------------------------Rock Size ------------ <br /> �--------------------------- -- �--------- -- � <br /> Distance to nearefst. Well -_ �__ -f--- - ---Fou dation =_- --- Prop. Line .. ---____...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----'------------------------------ Date ---------------------------------- <br /> II, <br /> _----------------------------•--- <br /> I, <br /> Septic Tank (Specify Re�qu4rements) ---.-- ----f---------- -------- 3 = <br /> ---------------------------- <br /> Ili ..,.� _ , __ y <br /> Disposal Field (Specify. Requirements) ------------ -- --------------------------------------- ---- <br /> :. '---------------------------- - =I------------------------------------------- -------- <br /> w <br /> <----------------------------------------- ------;Draw existing and -------------------------------------------------- __ = <br /> ' <br /> `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 /> j County Ordinances, Stat Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certi.,ies the following: <br /> "I certify that in the perfoi.rmance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to WII orkman's Compensation laws of California." <br /> Signed -- -:- --- lEl------ - -------------- ------------------- Owner <br /> Bt ----- ---- Title <br /> } -- ------ ------------ <br /> ter than owner} ,y <br /> ,- ARTMENT USE ONLY <br /> AF LIGATION ACCEPTED�IBY .-- DATE _. __` _---------------------- <br /> BUI'EDING PERMIT:ISSUED -------- ----------�---------- - ------------ --------------- -- -DATE ------------------------------------------- <br /> LIC <br /> -------------.---------------------------- <br /> ADDITIONALCOMMENTS` ----------------------------- -••------------------ -- --------------------- ------------------- ---------- <br /> 1 [` .� ------------S . ------------------- ------ ------------------------------------------------------------ ------------ ---------- ------ <br /> a <br /> ---- <br /> -----------------------3------ R _ i---------- <br /> ; + <br /> - ------------ ----------------- D -------=------- <br /> x� ---? <br /> Final Inspection by. ------------------------------------------------. ate__ .------i <br /> .r <br /> SAN JOAWN LOCAL HEALTH DISTRICT -W 9-6 <br /> I � <br /> l E. H. 9 1-'68 Rev, 5N1 �,, 3 'k 11 <br />