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y <br /> n FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------­----------I... Permit No. .._73-//..30 <br /> �� �-• �- - (Complete in Triplicate) � ' <br /> ................. <br /> ........................................ This Permit Expires 1 Year From Date Issued Date Issued .� .'� .:"13 <br /> ,....._. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> de,'Iscribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . .j._... ..._. ._-.-. P...... ..-•---.,/ .....-._...................CENSUS TRACT ..5. ...:..........: <br /> Owner's Name .....6Z. r. .. r....- ......................... ..Phone hone .•---•-•---........_..............•. <br /> N p� <br /> Address .........o . .__.�...._. _. -' Gcx►f.l4t![_.__. City ... ........................... <br /> -- <br /> c 1 F <br /> Contractor's Name ...... ._. ..- •---.._.. - ---- - ------ -------t9&..�_ '_f. _XML.. icense # _f.�_,:.3....� PhonIe .............................. <br /> Installation will serve: Residence [Apartment House Commercial ❑Trailer Court 0 <br /> Motel ❑Other --------...........----- ................... <br /> Number of living Gnits:--------4--Number-of bedrooms _, ......Garbage..Grinder..----------- Lot Size ............................................. <br /> Water Supply: Public System and name ----------------- ------........................................................................................Private 2 <br /> Character of soil to a depth of 3 feet: Sand❑ IIt C-] Clay Peat El Sandy Loam ❑ Clay Loam ❑ <br /> Hard A <br /> p dobe'j] Fill Material ------------ If yes,type ------__--.-----.------_.-. <br /> an <br /> it <br /> (PI plan, showing size of-Jot, location of. system in relation to welis,'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 i ] SEPTIC TANK[ I Size...................... ..........I................ Liquid Depth .......................... <br /> Capacity .................... Type __.___._..._. ..... Material...................... No. Compartments ................. <br /> ry <br /> ' Distance to nearest,• Wellp. <br /> ----=---------- ...............Foundation .......-.............. Pro Line ._.................... rn <br /> ' LE{,CHING LINE [ I No.-of Lines ------------------------ Length of each line---• --------------_:------- Total Length .......................... . <br /> r <br /> 'D' Box ...... Type Filter Material ....................Depth Filter Material ........._....._...._......_ ............... <br /> Distance to nearest: Well ------------------------ Foundation --------------._....--•. Property Line ........................ 0 <br /> w . <br /> SE!PAGE PIT E J Depth . Diameter Number ............................ ..Rock Filled Yes ❑ No ❑ 0 <br /> Water Table Depth Rock Size V► <br /> ....................................... ._._...---------•-..._.. ... <br /> Distance to nearest- Well Foundation .................... Prop. Line <br /> REPAIR/ADDITION{Prey':Sanitation Permit+# .._....................................... Date .................................. <br /> }eptic Tank (Specify Requirements) ...--•.................• �_. ...... ._.....-------------. •--...- ..... ...---•-•••_........... <br /> . C <br /> )Disposal Field (Specify Requirements) �.. --- ----- ---- - -------- ---- ... _....._. ...- -- ---- --•--------•--••-- • <br /> a... ... - ..._..__ �� X ' ' <br /> - - --- <br /> --•------------------ ----- --------I..._..........------ ------------------- - <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 /> CAnty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Iicen- <br /> seA 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 /> r as,to become subject rkman's Compensation laws of California," <br /> g <br /> Si Jned .--------- L .......... = Owner <br /> ByB ��...................... ..•---• -/ �...... ._... .- --- - V -------------• title ._ ._.... ............ ...... <br /> (if o er than owner) ;t V <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTER BY . ............•.......................•....................... DATE,�.��...�.+ .~rte ......... <br /> BUILDINGPERMIT ISSUED _'.._..................................•---.............-•---•---------------••--••----....a...:....-•----DATE ............... ..................... <br /> ADDITIONALCOMMENTS ..:........................................... ........................................ ..... _- -------.-..--_-------_.................. -- <br /> 0 _..........--•--•.................••-- ----................---................._._........ <br /> .. ...... <br /> . .................................. ......................••-•--••--•--------------------------....... <br /> ------------•..................•--•-- �' ................................................---•-••--••••--.:_....._...........-•----------.......-....................._.._..........- <br /> . <br /> .......................•--••-•-•-------- . ... ............. °_...... .. .................... •-----............................... _ <br /> Fi al Inspection by: ... .. "` .........................•-•---------.._.............--------.....•....Date . ..; _..._.._ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L <br /> F. H.13 241.'68 Rev. 5M 7/72 3-M <br />