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FOR OFT US� APPLICATION FOR SANITATION PERMIT <br /> ------------------------------ (/t --------------- <br /> (Complete in Triplicate) Permit No. __ _ _ <br /> / Date Issued __ <br /> ---------- <br /> /_- _ __0?_ ��___. / This Permit Expires 1 Year From Date Issued <br /> ---- -- - <br /> ✓7 611) 1 <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 ._ Jr --------------- ----------------------------------------CENSUS TRACT ---------------------.----•-- <br /> Owner's Name 6 11L,�------ -- --------------------------------- - --- ---Phone ---V9. �.�L�_ ... <br /> Address ----- ----- -- - ------- - City ----- <br /> Contractor's Name --- -- � �:/ '�� License #a� =$� _ Phone - -�'-ThlQ <br /> Installation will serve: Residence>6 Apartment House❑ Commercial ❑Trailer Court C] <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----I..... Number of bedrooms ___Z_.Garbage Grinder __-Aa---- Lot Size <br /> -- --------------------- <br /> Water Supply: Public System and name ----------------------------------------------------------------------------------------- ---------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loamf-] Clay 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.) O <br /> NEW INSTALLATION: (No ,septic tank or seepage pit permitted if public sewer is available within 200 feet,) X <br /> -1 t� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size_-_,/_6_.Y_S_____Y_ __________ Liquid Depth ___y ______________ <br /> p _ C o, "Compartments __tk................ <br /> CapakitY -���la------ Type Material N <br /> i -- - -_ _ <br /> Distance to nearest: Well ____________________________________Foundation __,/4-----------. Prop. Line __- --_-_____ <br /> LEACHING LINE [ ] No. of Lines ------a-____________ Length of each line----.676-------------- Total Lengthf _______________ <br /> 'D' Box -d^-- Type Filter Material -1 11 1" Cilbepth Filter Material -----117--------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ---/©-------------- Property Line ---S_-_............. <br /> SEEPAGE PIT [ ] Depth JDiameter 33.....-_. Number -------Z_______vv___-- Rock Filled Yese No <br /> Water Table Depth ------------ ---------------------------------Rock Size ---Z-A------------------- <br /> Distance to nearest: WeR ________________________________________Foundation ----t O----------- Prop. Line ..&�......._... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- -------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------_----------------- --------------------------------------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------'------------•------------------------------------------------------------------ --------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 Loc& 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 ------y----------------- ------------------- ------------------------ -------------------- Owner <br /> Bykl_)"-/,t'[ ------------------------------------------ ------------------------ Title ---------------------- ------------------------------------------------ <br /> (If oth an owner) <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � / - _ - ------------------------------------ --- DATE '� 7 <br /> BUILDING PERMIT ISSUED ----- ----------------------------- - -------------------------=-----------DATE <br /> ADDITIONALCOMMENTS --------------------------------------------------------'--------------------------------------------------------------------------- --------------------------- <br /> -------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- -------- <br /> ------------------------------ <br /> -- - - - - ------------------------------------------------------ <br /> Final <br /> - - - - - - - - - --- -- -=------- <br /> Date - L <br /> ----------- ---- - ----------- - --- ---- --- <br /> - - -- -------Final Inspection by �� � "7 ✓ ----------- --------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �> <br /> E. H. 9 1-'68 Rev. 5M �/ <br />