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FOR.0010E USE: APPLICATION FOR SANITATION PERMIT <br /> ................................. ............... Permit No. .Z._----------- i <br /> (complete In Triplicate) <br /> ..........I......::........................................ . <br /> Date Issued <br /> ................................... ...........­ Year-from. This Permit Expires I Yea -from Oaf*Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit <br /> mit to construct and Install the work herein <br /> d Regulations: <br /> described. This application.is made in compliance with County Ordinance No. 549 and existing Rules an <br /> JOB ADDRESS/LOCATION wr�,O-ze't .......-•----•............ ...... ............CENSUS TRACT .......... ............... <br /> Owner's Name .............................. ------- ..........Phone .................................... . <br /> Address ........ <br /> ...... City ........... . ......................... <br /> 1----------------­;�u --v <br /> # <br /> Contractor's Name <br /> Installation will serve: ---T-;9Residence License Phone Apartment House J-] Commercial OTraller Court E] <br /> Motel []Other....... ..................................... <br /> Number of bedrooms ---I------Garbage Grinder ........ ... Lot Size <br /> Number of living units:.---- ......................... <br /> Water Supply. Public System and name -------11------- ..........................._­................................................Private 0 <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay n Peat 0 Sandy Loom IJ Clay Loam 1� <br /> Hardpan 0 Adobe 0 Fill doterial ............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 f, SEPTIC TANK I L Size................;..........�a......... ........... Liquid Depth -__----- ............. <br /> Capacity Type ---------__....... Material...................... No. Compartments ••-------------------- <br /> ------------------ ---- <br /> ,4, %y <br /> Distance.to nearest.-Well ....................................Foundation .................._.. Prop. Line ..................... <br /> -------- ----- Length of each line--------q-0............ Total Len ......................... <br /> LEACHING LINE Na. of Lines' ......... L <br /> / tLength ... <br /> V Box Type Filter ...............Depth Filter Material .-_•---•--__-•-_............................ <br /> Well ........................ <br /> Distance to'nearest. ...........i.......... Foundation ......................... Property Line <br /> &&PAGGEW I Depth *_Xlr�A/hiometer ................ Number .......---/- -----• Rock Filled Yes jq No cl <br /> Water Table Depth ........_.........I——­--­I-----------..Rock size .................. -----__-- <br /> Distance to nearest: Well ........ .................................Foundation .................... Prop. Line ....i.......... <br /> REPAIR/ADDITION(Prev". Sanitation Permit# ...................n----_----_----------- Date r....................4.......... <br /> SepticTank (Specify Requirements) -------- .......... ........................... ...................................w----............. .............................. <br /> Disposal Field (Specify Requirements) __.-_---------------- ................................................................­................................ ........ <br /> -------------- ....... ................................ -------___.........................................................­...... <br /> ----------------------------•------------------------- . <br /> ---------------------------------------•---- <br /> ---------------------------6--------------------------- <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health,DIstdct. Home owner or licen- <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 ---- -------- -- ------------ ------------------------- ---------­­............ Owner <br /> ............................ .................. <br /> By .... . ...... --- --------­--------------------- Title-- -------- <br /> I Ifof <br /> e 4AJ <br /> f ot er n�owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... - -- -- -------------------------------------------------- ------------------DATE ...... .. -.2.. .... <br /> .. . ............ <br /> BUILDING PERMIT ------ .......I--------- <br /> ISSUED --------- -----------------------------------------------I.......- ----------DATE ........•-------...---------- <br /> .. <br /> ADDITIONALCOMMENTS -------------------------•--• ...........I........I.................... ............................ ......I—.................. ............ <br /> ------------------------------- ..............-1-------------------------------------------------------- ----- ................................ ---------------------------------- ----------- <br /> ................... ..•--•--.-......---......--•-- ---------- ..............**.......*...... ------------------------------------------------------ =------------------....... <br /> - <br /> - ------------------- - ----------------- <br /> ---------- <br /> .............. <br /> --------------------------------- ---------- ------- <br /> Final Inspection by: Date <br /> EH 13 24 1-68 ilev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />