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FOR OFFICE USE: <br /> 1. APPLICATION FOR SANITATION. PERMIT <br /> --------- I Permit No: -�-74-/_. <br /> (Complete in Triplicate) <br /> ---------- ---------- ------------- --- ------ Date Issued <br /> --- ------------ _--- -----_---_------,-------- �� This Permit Expires 1 Year From Date Issued <br /> - f7x-7— zw—c2 <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 i made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> Coc-�q_e_o"� <br /> p L ] _u C t -- :----CENSUS TRACT -------------.-•'---------- <br /> JOB ADDRESS/LOC ION . _�_6-�T.___ ��- -- <br /> ------- -- - -- <br /> Owner's Name Phone <br /> r <br /> City <br /> Address ---I/ <br /> Contractor's Name (' ----------- License # � - Phone. <br /> ` � <br /> -------- ------ - ---- ------- <br /> Installation will serve: r Residence �Apartment.House�❑ Commercial:❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <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❑ Silt❑ Clay .❑ Peat❑ Sandy Loam -❑ Clay Loam:❑ <br /> Hardpan y Adobe Cl Fill Material ------------ If yes, type ---------------------------- <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 it erminepublic� er i�mailable within 200peet,J <br /> TREATMENT [ ] SEPTIC TANK P p 1 Size.__ z__�l`�_ ___X--------- <br /> Capacity <br /> _ .------------ Liquid Depth -------------------------- <br /> PACKAGE ` _ <br /> 4 <br /> Ca acit ,.500 k T e _ Material ______ No. Compartments - -•_____________ <br /> P Y YP t <br /> _ f <br /> �J <br /> Distance to•neare Well ---------X--------------------Foundation ----1�------------- Prop. Line ---------- _-,-..._ <br /> LEACHING LINE [4= No. of Lines -_-___-_- ------------- Length of each line.... ------------ Total Length.,, _--_________-- <br /> - 'D' Box:.--- ---- Type Filter Material ---- --- ------Depth Filter Material ----�-�--------------------•---- --.----•- <br /> D Property tine. <br /> Distance nearest: Well ------ --------- Foundation �________________ p ty J'__----•-----•••--- <br /> Sr � x s <br /> SEEPAGE PIT [ j Depth !_v_Z_-- _.-_____ Diameter __ _ ____- ..Number ------- --------------- Rock Filled Yes No i❑ <br /> c l <br /> Water Table Depth ----------- Rock Size ax l '� <br /> i• <br /> Distance to nearest: Well __-------------/QP_f--------------Foundation -------/_O------- <br /> Prop. Line ..-_.----_-____-____.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date --------------------••------------} <br /> Septic Tank (Specify Requirements) -------------------- --------------------------------------------------------------- <br /> DisposalField (Specify Requirements) ------------------ -----------•------------------------------------------------------------------------------------------------------ <br /> --------------------------------------------------- ------------------------------------------ --------- ---------------------------------------------------------------------- ------------------------- <br /> ------------------- ------- ----------------------- --- ------------------------ ---------------I---------------------------------------------------------- ---------------------------- <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 /> "1 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." <br /> Signed ---------- - -----------------�i----nn---------- -- ------------------------------ Owner .{ <br /> U Title _.-- ----------- <br /> By ------ ----- - <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ---------------------------------------------------------- DATE _7` _ . , ~ ----- <br /> BUILDINGPERMIT ISSUED -------------------------- - ---------------------------------------------------------------------DATE ...... ----=-----------------------•----- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------- ------------------------------------------ ----------------- --------------------------- <br /> --------------------------_--------_--------_________3___--_---_____----___-____._____-----_----------__-_---------------------------------------------------------------------------------------- -------- <br /> ----------------- -------------------------------- ------------------------------------------------------------------ <br /> ____________________________________________________________________________________________________________________ _______ <br /> _________________________________________ ____-_-___.__------.--.___--_--_-.-_______-------___ -__ <br /> ___ .__ y� -_ _ _ __ <br /> i Final Inspection by: --- ----------------•----------- ---------------------------------------Date = ---- - ---- <br /> ---------_________._-_--_-__.__ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1268 Rev. 5M <br />