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FOR OFFICE USE: y�'O APPLICATION FOR SANITATION PERMIT <br /> - <br /> ------------------------------------------------ (Complete in Triplicate) Permit No. -- --------------- <br /> ---------- <br /> -- <br /> ------------- ------- ------------------------------- <br /> - <br /> �. .7.-:�Z� <br /> -------------------------- --------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 S£..-k---- ---------- 1Zp(._ --- --QCo-.CENSUS TRACT -------------- ----------- <br /> Owner's Name ---p_��------ - ------ -------------- -------'�-�--.`4`.'�''-`4------------------------------------------------Phone ------------------------------------ <br /> Address -----------YJS � � ------- - - --' - City ----- }------------ -----------------------------•-•------- --- <br /> Contractor's Name (per.:�. .. --• i4- e License # Phone <br /> Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court <br /> Motel ❑Other _. x-•-—--------------------�-�'L �r�✓ <br /> Number of living units:--- ---- Number of bedrooms --— Grinder .---------. Lot Size _-_._--.__-------------------------------- <br /> Water Supply: Public System and name ---------------------- --------------------=---------------------------------------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy LoamClay Loam ;❑ <br /> Hardpan ❑ Adobe ❑ Fill 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------_------------ Liquid Depth __----.--.--------_---- <br /> Capacity ---`----------------- Type ------------------- Material---------------------- No. Compartments ---- ................. <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------..-.---_--_--- <br /> LEACHING LINE [k No. of Lines ---------1-------------- Length of each line----_-.5-0...------___. Total Length ,_ c.................... <br /> 'D' Box . ._ Type Filter Material ---L-A .......Depth Filter Material .._/__ _'r..-__........................ <br /> Distance to nearest: Well -------L-CSO- . Foundation ----lQ--------------- Property Line ----- <br /> PIT [ Depth -_-_ 21 S-_'_-_- Diameter _.41S--_M_ Number ----.__-/_--_---_----- Rock Filled Yes No 0 <br /> Water Table Depth S Rock Size .-.---�i--- -- / — ._.- F <br /> ---------------------------- ---- <br /> Distance to nearest: Well ---------!So_`--------------------Foundation .-.-ke'-.`------- Prop. Line --.$---.---•----.--. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------.) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ----------------------------------------------------- <br /> Disposal Field (Specify Requirements) --------- _ 2..... <br /> - ' T---------------------- <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 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: <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 /> .�,.�..� ,� - -- � -------------- <br /> BY -------- --------------------------- Title -- C �.c - <br /> (If other than owner) <br /> 00 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . -------------------------------------------------------------- DATE --------- --------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------------------- --DATE ------------- ---------------- ------------ <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------•-------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- <br /> ---------- ------------------------------------------------------------------------------------------------------------ -------------------------------------- -------------------------- <br /> ------ ---- ---------Date <br /> --- --- - ----- -- ----- - -- ------ <br /> Final Inspection by: ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />