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FOR OFFICE USE: <br /> " APPLICATION FOR SANITATION PERMIT , <br /> -a....... -- <br /> Co�..�.-_/�-�.�_.��-r----------------------- (Complete in Triplicate) Permit No. <br /> --------------- This Permit Expires 1 Year From Date Issued Date Issued 11- _-W <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 __///Cl_A -,Z-:-.__51--- <br /> ---- ----------- -----------------------------CENSUS TRACT -------------------------- <br /> Owner's Name _r. JC '-1 �� ^�qy <br /> f ----- - ---Phone -y --- ----- -- <br /> Address --- ,.3/14110 t1l/V6-TTL �---------------------------•--. City --- -------------- = ------ <br /> t <br /> Contractor's Name �--------- T ------------------------------------------------;--------License #--------:------------- Phone ---------------------------- <br /> N <br /> s . <br /> Installation will serve: Residence [impartment House❑ Commercial :❑Trailer Court !❑ <br /> f <br /> Motel ❑Other -------------------------------- <br /> Number <br /> - ----------------------------Number of living units:-.-/------- Number of bedrooms ---I __Garbage Grinder _1V0---- Lot Size � ______________________ <br /> Water Supply: Public System and name --------------------------------•--------------------------------------------------------------3-------------Private ❑ <br /> Character of soil to a depth of 3 feet:Hardpan d Silt Clay Material ____,___SandyIeLoam ❑ Clay Loam ❑ , <br /> p ❑ _ ❑ Y ❑ ❑ �i <br /> ❑ C 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 [ J Size-----------------------------------•------------ Liquid Depth ------------------------ <br /> CapacitY --------------- --- Type -------------------- Material---------------------- No. Compartments -- --•---- •--._---- <br /> Distance to nearest: Well ------------------------------------Foundation ----------------------.Prop. Line --------------•,_....- ti <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line--------.__------ ----- Total Length _________-___.__..__....-_ � <br /> 'D' Box --------..-- Type Filter Material --------------------Depth Filter Material -------------------•------------------------ 1} <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line. _______-_---__-___---_ <br /> SEEPAGE PIT [ ] Depth ---------- Diameter ________________ Number -------------------------- Rock Filled Yes ❑ No ,,o <br /> Water Table Depth ---------------------- ------------------------Rock Size ---------------------------- <br /> Distance to nearest: Well -Foundation -:------------_---- Prop. Line ---------------_----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date ---------------1-------------------- <br /> Septic Tank (Specify Requirements[ - A <br /> DisposalField (Specify Requirements) -------------------------------------------------------------------------------------------------•------------------------- -------- I <br /> I <br /> -- ----------------------------- --------------------------------------------------------------------------------------------- --------------------------------------------------I------------------------ <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: i <br /> "I certify that in the performance of the work for which this permit is issued, t shall not employ any person in such manner <br /> as to beco a subject o W rkman's Compensation laws of California." <br /> Signed _✓ <br /> - --- -------- --------- - -------------- --------------------------------- Owner <br /> BY --------- ----- Title <br /> ----------------------- ------------ --------------------------- - <br /> (if other than owner) I <br /> EPAATMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- ---- -------- <br /> ------------------------------------------ DATE ...10_74Z!`�P" .--------- ------ <br /> - - <br /> BUILDING PERMIT ISSUED - --------------------------------------------------- - -DATE ------------- ------------------------------ <br /> ADDITIONAL COMMENTS ------ ----------------- ---- ------------------------------------------------------------ <br /> -------------------- ------------- ------------- ---- -- -- --- ------------------------------------------------- ------------- --------------------------------------------------- i <br /> ---------- ------ - -- -------------------------------------------------------------------------------- ---------------------- -------- <br /> Final Inspection b ------Date -- <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M ."A <br />