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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .............. Perm <br /> ........... ... ... .. .......... <br /> (Complete in Triplisabl <br /> ���, � Dais Issued�a.:.a�"��J� <br /> ............... This Permit Expires 1 Year from Dade 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 ..-...... - 1.3..�... � . ..... <br /> s ___. .... . ,._.... ......... .........................CENSUS TRACT ..............,........... <br /> Owner's Name �.G�U�....Lr ...........................PhOrW1, 1 <br /> Address <br /> -1-70-1-1 - 'I. s'z city . ,...lq .................................... <br /> Contractor's Name .. ,f +�. ......-----••...............•.•......................License dt .... Phone ..kg7.n.1133... <br /> Installation will serve: Residence[P Apartment House 0 Commercial❑Trailer Court ir] <br /> Motel(]Other............................................ <br /> Number of living units:-A ...... Number of bedrooms _al.......Garbage Grinder ..X0... Lot Size ?-.rj'Com.................. <br /> Water Supply: Public System and name .............. ............._...................._....................................................Private (� <br /> Character of soil to a depth of 3 feat: Sand 0 Silt❑ Clay Q Peat Q Sandy Loam 0 Clay Loam Q <br /> Hardpan M Adobe Q Fill Material ............if yes,type............... ............ <br /> (Piot 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 j l SEPTIC TANK$ j Size................................................ Liquid, Depth .......................... <br /> Capacity -------------------- Type .................... Material.........._........... No. Compartments ...................... N <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line............................ Total Length ............................ J <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ...........................................I eW <br /> Distance to nearest: Well ........................ Foundation -.-................,_... Property Line ........................ T <br /> SEEPAGE PIT [ j Depth -------------------- Diameter ................ Number ............................ Rock Filled Yes ❑ No HCl , <br /> Water Table Depth -•---•------• --•••-•...........................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ ....... Date ..................................I <br /> SepticTank (Specify Requirements) ......... ............................................................................................................................... <br /> Disposal Field (Specify Requirements) -.041 •-S..f7. . . .. ... ...- <br /> 0. <br /> ..----.....-•------.--•--•-- ---•-•---- --------- .--........---___•_... o �.�_... ........... ........ <br /> -------------------------- ------------- ------- -_...............- ............ ..............-.•-•--••..•....•. ............. ...................V- <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 M accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Hear.District. Hence owner or 114M <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 ---------- p ...... Owner <br /> By --------J - ---------------------------------- <br /> (If other than owner) ------------- Title C'.�,n.ccc! ................ ...................... <br /> EOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .-- ....... .................... DATE . ,�. .-./..�' <br /> BUILDING PERMIT ISSUED .... --------------------- <br /> ----------------- -----•-...... -------DATE -----.................................... <br /> ADDITIONAL COMMENTS ..........................................••-. ._........ .. <br /> --------------..._.......... -----------.....-------- -----........._.........--. .................. <br /> ....._..-•-_.-.-...._...---............................. <br /> ................ <br /> - = ...... . -•-•-- <br /> ------------ <br /> Final inspection by: . -•... .... . .. ...... ------------------------ .............Date .. ....J..47 //:-7 <br /> ---........-•••--... <br /> EH 13 2h 1-68 Rev. 5m SAN JOAQU& LOCAL. HEALTH DISTRICT $/7b 3M <br />