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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- - ------------- <br /> ---------------------------------------- <br /> 73 -y-aS- <br /> ------------ <br /> } (Complete in Triplicate) Permit No_ -------------_------- <br /> -------------- . <br /> --l - -- ------------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._ 2_0__Z12__67_1_1�----- .e�__A&r_1___L` _ ----------------------------CENSUS TRACT _-_____--_--_---__-_-____ <br /> Owner's Name ------ -------Phone . - - 7 <br /> Cit <br /> Address ✓t_ �'' - <br /> Y - ---- -7 -------------------------------•--- <br /> Contractor's Name ----.License # -0C-�J�� /__7 Phone <br /> Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Mote ❑Other -------------------------------------------- <br /> Number of living units:--- Number of bedrooms ---3------Garbage Grinder ------------ Lot Size ----129K?zefr�------------------- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe I 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---- �'__._`l�_ -__ Liquid Depth -------------------------- <br /> Capacity /Zo_1'------- TYPeaMaterial__6 - No. Compartments_ <br /> Distance <br /> l <br /> to nearest: Well _______._________-_-____________-Foundation ----/_0------------ Prop. Line ----- --------- <br /> LEACHING LINE [ ] No. of Lines ----- ------------ Length of each line-_-- -_---------------------------- Total Length ,_________,.__-.--____-•-_- <br /> 'D' Box __ _ Type Filter Material ----I_)��edpth Filter Material -I----jJJ___________________________•__._ <br /> Distance to nearest: Well ________________________ Foundation --------f__0---------- Property Line _____6'".......... <br /> SEEPAGE PIT [ ] Depth _________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth --------------------------------------- --------Rock Size -------------------•---•-------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------------_---) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------- ----------------------------- _------------------------------ <br /> Disposal Field (Specify Requirements) -_.__._.__-_ --------•- <br /> ------------------ ------------------------------------------------------------------------------------------------------------------- ------------------------------------- ---------------------------- <br /> ------- <br /> -------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 /> BY1 - -- - ------------ ------------------------------------- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPA4XMENT PR ONLY <br /> u22�- <br /> APPLICATION ACCEPTED BY ----------------------------- <br /> 2 DATE r." - <br /> BUILDING PERMIT ISSUED .----------------------------------a----- -------------------- ------- ---------------------DATE ------------- ----------------------------- <br /> ADDITIONAL COMMENTS --------------------------------------- ----------------------------- ------------------------------ --------------=--------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------_------------------------------------------------------------------------------------- ----------------------------------------- ---------------------------------------- <br /> -- - - -- - ---- <br /> ----------------- <br /> Final Inspection b <br /> - <br /> PY- ------------------------------------------------------------------------------------------- Date t1�� <br /> SAN JOAQUIN LOCAL HEALTH 6SWICT <br /> E. H. 9 1-'68 Rev. 5M <br />