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FOR OFFICE USE. �i <br /> APPLICATION FOR SANITATION PERMIT /�� <br /> (Complete in Triplicate) <br /> -------------- <br /> Permit.No. �l1-Y--------------- <br /> ________________________________________ .___________ This Permit Expires i Year From Date Issued <br /> Date Issued J____.____'_____. <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 /> �v ad <br /> JOB ADDRESS/LOCATION .._ _ _______---- ---------- -- 4 &w <br /> ---- �_______._._ --X:.---.CENSUS TRACT -------------------------- <br /> Owner's Name .%1 )z- 4 ���� - ---� �- ---------• ---------- -------Phone f-------�, c... <br /> Address X1-39-----7)14---W,1�� -v,17----------------'----------------•--- City -----------------------------------------•------ <br /> Contractor's Name t gs <br /> ---------------License # �Z X Phone ------------------------------ <br /> Installation <br /> ----G�--J-'---f--•S-1-- <br /> ---•-_ <br /> Installation <br /> will serve: Residence ❑Apartment House°E] Commercial ❑Trailer Court ❑ <br /> Motel XOther ---------`.------------------------------------ <br /> Number of living units:-- --- Number of 1 IJedrooms� ""`=_ ='--.Garbage Grinder ------------ Lot Size _____________ <br /> 1 r ---- Private <br /> Water Supply: Public System and name ----------------------------- <br /> Character of sail to a depth of 3 feet: . Sand'❑ Silt t Clay ❑ Peat ❑ Sandy Loam ❑ j Gay Loam ❑ <br /> ` Hardpan ❑ Adobe Fill Material ------------ If yes, type ___________________________ <br /> § s F <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,) 4 <br /> i PACKAGE TREATMENT:[ ] SEPTIC TANK'{ ] Size-----------------------------------•------------ Liquid Depth -------------------------- �+ <br /> "Capacity '------------------- Type -------------------- Material---------- ----------- No.. Compartments - ............... <br /> =---- <br /> ;.';`Distance to nearest: Well, _______._________________________Foundation -_.------------------- Prop. Line ___.___--__..:..__..__ <br /> Z_; + C-r . <br /> LEACHING LINE [ ]; No.3of Linesr________________________ Length of each line---------------------------- Total Length --------- ....... <br /> 4 D' Box ------------ Type Filter Material ----------- --------Depth Filter.Materia! ---------------------....................... <br /> I <br /> Distance to nearest: Well -------------------- "Foundation _______________________ Property Line. ____________...._,...._. ' <br /> SEEPAGE PIT [ ] Depth ---- --------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No ,C] <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> 1 - <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ---------------------- <br /> ! <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___--------------------------_---------- Date ---------------------------------_) <br /> Septic Tank (Specify Requirements) -------------------- -- 11-------------------------/---------------------------------------------------------.-------------- <br /> Disposal Field (Specify Requirements) ---------- <br /> ---------------------F-------------------------------- ------------------------------ ------------------------------ -----------------------------------------------------------I-------------------- <br /> -------_-._.________________,_______________________.________.___.__________.___________________-_-------__._____________________________-__--____-___________-____________-______-___--I_____-______-________ <br /> 4.➢ <br /> It <br /> -------------_------------------------------------------_____,______________________________________________I_._________________________________-___-_________.--______________-___._____________________ <br /> 4+, I (Draw existing and required addition on reverse side) <br /> ,t .I hereby certify that I have prepared this application and that the work will be done in accordance with! San Joaqu <br /> j County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or liicen- <br /> sed_agents signature certifies the following: f <br /> i <br /> ".'J ceftify that in th_e_performane yof the work for which this permit is issued, I shall not employ any person in such manner <br /> as tS,be psub;ect,to ork a 's CompensathM laws of California." <br /> Signed g -- ---- �•-= - ' --" - _ - - -" -- -- - ------------- A--------------- Owner <br /> BY ------------------------------I- --------- -- - <br /> .G - - --------------- Title ------=------------------------- -`--------------------------------- <br /> {If other than ner)I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . 9 ------. DATE -z- z 7- 70----------------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------- --- ----------DATE <br /> ADDITIONAL COMMENTS _z-_ T.o----- <br /> --------------------=------------------------------------------------------------------------------------------------------- <br /> 1 <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- -=---- -- <br /> - ------------------------------------------------------ -- ----------------------------- - -- ------- --- - - -------------- ------ <br /> Final Inspection by- � ------------------- ------------------------------Date - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> , <br />