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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No7.�.....-- � <br />..._r::...........:.... ,._ (Complete in Triplicate) <br /> .._...._+............................I.....-- ._..... <br /> Date Issued <br /> This Permit Expires 1 Year From 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 ._..� - ,..:_C'LI.� c. -•••-- ..r .C. _�-P�,,:.CENSUS TRACT .....................:.... <br /> SF_-rG..1•----••--•-•--•................................... .....................P e _... --..... <br /> Owner's Name .�. �...?.:..---��/ ............. <br /> Address ...__/�`�/---------L %T.�/ - :...... ............City _ . ............ <br /> L+cense # - _17. Phone <br /> Contractor's Name --- T. !£. .. ��partment <br /> .�! ----• i <br /> Installation will serve: Residence House Q Commercial oT:railer Court 0 <br /> Motel ❑Other ___ <br /> Number of living units------ Number of,bedrooms ---�--=Garbage Grinder--- :.__-=---Lot Size .... ....... < <br /> Water Supply: Public System and name ..._.__. <br /> ....:......_.- - Private (] <br /> Character of soil to a depth of 3 feet: Sand [] Silt Clay Peat Q Sandy Loam ❑ Clay Loam ❑ <br /> ill Material ............ If yes,type----...--•--... ............ <br /> �1 <br /> Hardpan ❑ Adobe .x _ Y y typ <br /> l t Ian showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.} , <br /> (P o p g x <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> .PACKAGE TREATMENT [ ] SEPTIC TANK f ] ` ' . ...._f--------------•------------•--••....••• . Liquid Depth ...------•-- <br /> jCCs IT�J 4; Capacity --------- -------- Type ------------ ------ Material---------------------' No. Compartments ....... <br /> Distance to nearest: Well ----------------_------------------Foundation ----•................. Prop. Line ---_---------_---. <br /> LEACHING LINE [ ] -7 No. of Lines .. Length of each line------- ----------- Total Length ............................ <br /> 'D' Box ......__.... Type Filter-,Material ...Depth Filter Material ....... ..................................... + <br /> Distance to nearest: Well Foundation Property Line ........................ <br /> Diprrieter NiTrl3er .... Rock Filled Yes <br /> SEEPAGE PIT [ Depth; .. � � r� . <br /> Water;Table Depth _... ....._ .................Rock Size . ..._ <br /> < <br /> Distance to nearest. Well ---- ....-----._Foundation /.0........ Prop. Line . ------.... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ` ...----_- ... Date .................-------------.... <br /> ) , <br /> Septic Tank ($pecify Requirements) ----•_.. ................................. -- ----------•----- -••----- •-•-- ............:.... .............. <br /> ._ <br /> Dis I Field (Specify Requirements] --: — --.. <br /> _ ... ,...rte. <br /> __________ ____________ <br /> ._ _ _ ____.__. ___________ ___ _ <br /> -----------------------------------------------.----------_-----,.____..____.._-__ __....____....._...._....-__-__________-----___.__._.____-..__-_.._.__-_---______..._____-.­------­-------------------- <br /> +i (Draw existing and required addition on reverse side) <br /> k 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 Itcaft <br /> sed agents signature certifies the follaWhig: <br /> "I certify that in the p armance of the work for which this permit is issued, I shall not employ any person in such manner <br /> r as to become subje t War ma 's Co pe tion laws of California." <br /> Signed ---------------- --.. lam - ---- ........ --------- - -----a Owner <br /> . - - <br /> - <br /> -•---- Title .... <br /> (If other than ne • <br /> FOR DEPARTMENT USE ONLY <br /> ---.-. DATE .._ L�. .., _� . . <br /> ! APPLICATION ACCEPTED BY _._ . --- -•-.` -:- ; 'ZiS-�---------------•-------- <br /> BUILDING PERMIT ISSUED ----------- DATE -. <br /> ADDITIONAL COMMENTS ----- -- - <br /> ....------------------ <br /> •-------------------- •------------------•-•------------- ------------------ -...--•. ----• <br /> ..-----.....------------•--•-----------•-••-------------------------------------- <br /> ....... <br /> .------- <br /> .............. <br /> ......... ....................... ........... ©ate ./ .._.......-- <br /> Final Inspection by: _. <br /> .. <br /> EH 13 24 1-68 Rev SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br /> � �W- <br />