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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..................... . [/ <br /> (Complete in Triplicate) <br /> ....................... ..... .. Permit No. ..._.....'.._. <br /> ...... This Permit Expires ] Year From Date Issued Dote 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 /> J013 ADDRESS/LOCATION ....._ ........ <br /> ..............CENSUS TRACT . <br /> ........................ <br /> Owner's Name .._......10141/6------- . /. .................... .................................................Phone <br /> Address .................... ;••'i• :.. City .......... ... } <br /> Contractor's Name ..AcC T.....° . re---- 1 _.. , ".License # 427.1?1�3.... Phone: ..- <br /> Installation will serve: Residence SApa.rtment-House-❑-[-ommerciol-:6Trailer Court-0-1A <br /> € Motel ❑Other ................ ........................... - s <br /> Number of living units:.____.... Number of bedrooms ......Garbage Grinder ---,f.V Lo,t Size lf�_ C._ ................. <br /> Water Supply: Public em and name Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ -Silt❑ Clays❑ 'Peat❑ Sandy om 0 i"rtCloy Loam ❑ <br /> I Hardpan ❑ Adobe.[a Fill Material ............ If yes,type ...--.__..._- _ ------ . <br /> (Plot plan, showing site of lot, location of system in relation to wells, buildings, etc. must be placed onl�teverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,jF. <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] Size------------------------------------------------ Liquid Depth4...=.................. <br /> __--x <br /> Capacity; Type .-=----------------- Material---------------------- No. Compartments' -- ••---...._..::_..S <br /> Distance oto nearest: Well ....................................Foundation .....----------------- Prop.tLlne ... ..._...______-••-• <br /> LEACHING LINE [ ] No. of Lines.------------------- --- Length of each line------------------.--------- Total Length .._.__...°__•-------_.......T"! <br /> i y I V <br /> 'D' Box ...,___..... Type Filter Material ....................Depth Filter Material --------- ........................ <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ................. <br /> SEEPAGE <br /> SEEPAGE PIT [ Depth ___ ________________ Diameter ................ Number .__'_{_`.,. };ti b______. Rock Filled Yes j] No t❑ <br /> Water Table Depth ...Rock Size <br /> # Distance to nearest: Well ........................................Foundation .............. <br /> --•.. PropAine ...}.. --------- <br /> 1 , <br /> REPAIR/ADDITION(Prev. Sonitoti!'Permit'# ............................................ Date .................................. I <br /> SepticTank (Specify Requirements) .................:_...........-........... .......................................•......................................-.......... <br /> € # 3 <br /> Disposal Field (Specify Requirements) ---....A ------ ------- L-7------------------------- ............. ............. <br /> j <br /> ------ •--------------------------•-•----- ----- - ------------------------ ---------......­­­............................. .... -- - - ------F---.....-._.. ..... <br /> ------------ <br /> (Draw existing.pnd required addition on reverse side).,, i i ! <br /> 1 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 Son Joaquin Local Health District. Home owner or liven- I <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 become subject to Workman's Compensation laws of California." ` <br /> Signed .............................•• <br /> Owner <br /> By <br /> Title — ........................... <br /> (if other than c ner) <br /> t FOR DEPART USE ONLY <br /> APPLICATION ACCEPTED BY_. __ ' <br /> ...................... DATE ..---•-•--•-------•------•--- -----••---- <br /> BUILDING PERMIT ISSUED <br /> ADDITIONAL COMMENTS ............ .... <br /> ......._ <br /> ....................................................... ---------------- --•-----•-------•-----------------------••-----------•-----•---------------------•------------•--------- <br /> �. <br /> :... <br /> Final Inspection by: ... .._ Date <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E, H.13 24 1.'68 Rev. 5M ,i'' n 1 s 's: 7/ 3 Hri <br />