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FOR OFFICE USE. `� <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. .._. ...-..- <br /> -"•••.................---•••••••---•-_••••-•.......-. This Permit Expires 1 Year From pate Issued <br /> Date 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 76:710... <br /> m��ade in compliance with County Ordinance No. 549 and existing Rules and Regu cations: <br /> JOB ADDRESS/LOC ON ......6 0 r <br /> ........... <br /> ........... CENSUS TRACT <br /> ....... <br /> Owner's Name .. .. _ ��- h ...... <br /> - - •-----••• -• .. ...z,7 ...P one <br /> Address ..._..._.... ............. <br /> ---------"... .� ' <br /> ... ... �.�.�•----.... <br /> City- <br /> Contractor's Name <br /> :_.... ���tment__House_C­Commercicil <br /> License # ",3 Phone <br /> Installation will serve: Residence .❑Trailer Court 0 <br /> A <br /> Motel ❑Other ...................................... ...... <br /> Number of living units:--------t Number of bedrooms _...-,3-._Garbage Grinder.. : A_�� - Lot Size .... <br /> �..� � ,' = <br /> Water Supply: Public System and name ^:..._-_-- • "-•- •-. .._._. ............"_-•- ,y <br /> --------------- ..........__..... ..._...Pri <br /> va <br /> to V <br /> Character of soil to a depth of 3 feet'. Sand L3 Silt❑ Clay eat Sand loom 06y,Loam (] <br /> Hardpan C] Adobe ill 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.) O <br /> NEW'INSTALLATION: (No septic tank or seepage pit-permitted if public sewer is available within 200 feet,}ki i <br /> PACKAGE TREATMENT [ ) r <br /> SEPTIC TANK t ) Size................... ...................--------- Liquid Depth i <br /> •�� Capacity ' <br /> .. Material............... No. Compartments <br /> d , Distance to nearest: Wellf <br /> ..............Foundotion Prop. Line . <br /> LEACHING LINE [ j .1 No, of;Lines ' <br /> Length of each line_______________ ___. Total Length <br /> t>, <br /> �x� Type Filter Material ...................... <br /> .- ••----••---•........... <br /> Distance to nearest: Well ..._:.__.._."•:• •--.•• Fou-•�--"De..Depth Filter Material E <br /> - .....---•-. {� <br /> f• F ._..._................................... <br /> nd`ation _.----__ Property Line ................. <br /> ........ <br /> . Number ..__.... <br /> SEEPAGE PIT ( j _ Depth`V� 'Diameter Rack Filled Yes ❑ No <br /> Water Table,Depth ....................Rock Size <br /> Distance to nearest: Well ........................................Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitdtion'Permit# _.."'... <br /> Date ..................... <br /> S— <br /> ; <br /> FSepfi,Tank (Specify Requirernents) <br /> t <br /> Disposal field (Specify Requireentsj {, ......_... --• ......................... <br /> •- --•--. _.M.---•-----,.-..-. <br /> r `.- <br /> / ............. <br /> *(!i "' I-------------- <br /> y -••--•................................ . .............•-•...................._.......... . . <br /> ;..._ ._. <br /> - - -.-• -----•-- --- <br /> (Draw eXlStln2� •--- <br /> and-.reqadd'rtfOn On fever5e Side-------------- <br /> --------------------------------- <br /> ••••••"• <br /> I hereby certify that I have prepared this applicationmand 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: `r• - ' <br /> "I certify that in the performance of the work for which thi's perm it.is.issued, Ishall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of CaIlFornio." <br /> c• <br /> Signed ......... � <br /> s r <br /> ner '"' i <br /> T' <br /> of than ow6V . <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . <br /> .... <br /> ...... <br /> -- ••-•-••-- x,r...............••......._-. DATE .. :_ _L�• <br /> BUILDING PERMIT ISSUED . ..:--.....--_-• - <br /> ADDITIONAL COMMENTS ..... ...... .....•--•-.... -•••----• ............ .-•-•--.. ......_...DATE <br /> .......................................................:. ..................................... <br /> ._ _... _._. ------------------------ <br /> ._ -----"....-••_--•--•-• ............................................................................. <br /> --..__..._.I......................... .......__ ..: ... - <br /> _..- ... --•- ... ...... .............. <br /> .. . .......•- <br /> Final inspection by ©ate .... <br /> ........--•--•. ... .......................••••--• -- <br /> SAN JOAO, LOCAL HEALTH DISTRICT <br /> W Z� <br /> E. H. 13 241-'68 Rev_._5M _ _ 7177 1.M I <br />