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FOR OFFICE USE: h <br /> E: 14 APPLICATION FOR SANITATION PERMIT � }S <br /> wy •� �3r�J <br /> - -------- -------- -- Permit No. -A------ --------- <br /> Date <br /> in Triplicate) r. <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> -------------------------------------------------- 1 <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 Aeg---S-01-------10141 /CJI/F--------------- ---- --- ---- ------CENSUS TRACT -------------------------- <br /> Owner's Name 1PT .... ---- P.C3 f Phone <br /> Address �`- --------------------------------Z----------------------------------------------- City - _G/ 0_4x------------------------------------------ <br /> Contractor's <br /> -------------------------------- •-Contractor's Name -------- ---------.License # /7,,72TIF .-- Phone04,1:7S6'2 <br /> Installation will serve: Residence 0 Apartment House❑ Commercial ❑Trailer Court <br /> i <br /> Motel ❑ Other -------------------------------------------- <br /> Number <br /> ------------------------------ ----------Number of living units:-./------- Number of bedrooms _- _---Garbage Grinder r✓4___ 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 Loom ❑ Clay Loam[] <br /> Hardpan ❑ Adobe ° 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 pit permitted if public sewer is available within 200 feet,) . <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ------------.._-.._-_----- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------.--.--_._-- <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ---------------------___-_ <br /> LEACHING LINE [" ] No. of Lines _ Length of each line----- ------------------- Total Length _--_-_.----•------___---- <br /> 'D' Box .----------- Type Filter Material --------------------Depth Filter Material -----------.----------------------- <br /> ........ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line __-___--..._....__.__--_ <br /> SEEPAGE PIT [ ] Depth ---- Number ----------------- -_ Rock Filled Yes No <br /> -- ------------- Diameter ------------ - ---- ❑ 0 <br /> Water Table Depth -------- ------ --------------------------------Rock Size -------------------------------- k <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------- ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------._.--_---_--__---_-_--) <br /> Septic Tank (Specify Requirements) --------------i- ------------------------------------------------------------- ----------------- --------- <br /> - <br /> Disposal Field (Specify Requirements) -------�� --- � IV---,4/� _---1!5�V11------A_7_ 1`_,_�J- --1DIT--------- <br /> ----------------------------------------------------------------------------------------- ------------------------------------------------------------------------"------------------------------------- <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: j <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 become su ect to Workman's Compensation laws of California." <br /> Signed --- j --- -------------------------------------------------------- Owner <br /> BY ---------------------------------------- ---- Title ----------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> --rfr- - / <br /> APPLICATION ACCEPTED BY - -------� =Y -----------------------------------------. DATE: - --'--- 7-6---------- <br /> BUILDING PERMIT ISSUED ---------------------------------- _-DATE ------------------------------------------- <br /> ------ ---------------------------------------------------------- <br /> ADDITIONAL COMMENTS --------------- ---------------------------------------- ------------------------------------------------------------------------------------------------ <br /> ---- =� " ti - i Y ----- - ------ --- --------------------------------- - --------- - --- --------------------------------- ------- - I----------------- <br /> Fi ---------tion------- ------ - -- <br /> ----------------------------------------------------------------------------------- --------- - - -- <br /> Final Inspection bY: �' Date -,J�^�s ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />