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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------------- Permit No. -7�- <br /> ------------------------- <br /> (Complete in Triplicate) <br /> ,�'A - o z 9 <br /> Date Issued __�..:.......:.... <br /> -------------- This Permit Expires 1 Year From 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 <br /> /Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .{ --=- �11'- �d-�!'---- i---- - CENSUS TRACT __._..................... <br /> Owner's Name _, � ------- ---------- --------------------------------------- Phone= ._. <br /> Address ---- , `7�`� r 11 - '.------------ --- City ------------------- ------------------------------------------ <br /> FIr <br /> Contractor's Name ---- �� .�.}`�!Y--- -----------------------------------------------------License t23.� � a <br /> PhoneC- -Z , <br /> Installation will serve: Residence [lxpartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- //' <br /> Number of living units:--/------- Number of bedrooms ......Garbage Grinder - ------ Lot Size ----1�-'=o �.. <br /> Water Supply: Public System and name ------------------------------------------------------•-----------._.-- ......................Private 13� <br /> Character of soil to a depth of 3 feet: Sand'ar-l*Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted ifpublic sewer is avail able within 200 feet,)tL ~ r <br /> PACKAGE TREATMENT [ ) -SEPTIC TANK'[ Size-?-- * -�_YR-..---. Liquid Depth _-T------------------_ <br /> dap yp <br /> Capacity/ T � _i` - Material 't'lG l,� No. Compartments................ G,� <br /> i <br /> Distance to nearest: Well _ _ 16001001�160.Foundation lQ_'e------------- Prop. Line/0-6------------- <br /> .00 <br /> LEACHING LINE No. of Lines .2 Length of each line_a0----------------- Total Lengt .Cp��--- <br /> 'D' Box L' _ Type Filter MaterialKank----. Depth Filter MaterialIf---____-___..........I............. <br /> Distance to nearest: Well -- --------- Foundation -------------- --------- Property Line/00............... <br /> ,&E-411AGE P11 [ter Depth ---M-'*-------._ ENowmter T;VA 0____ Number ------�________________ Rock Filled Yes '[j-No 0 <br /> F:/leti. ieds Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> AQP/ Foundation _ <br /> 1- --.-__. Prop. Line _._� �--.- <br /> Distance to nearest: Well ____ 1+�f?-________-____ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________-__-____----.-_-_ ------) ' <br /> Septic Tank (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 Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - t -- ---------------------------------------- Owner <br /> By ---------- �� -� ------------------------------- Title � / A f "J� i' <br /> If o-tTier titan owner <br /> l ) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _...--- - '---- ---------------------- DATE ----- - ��1-------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS -------- ---------------------------------------------•------------------------------------------------------------------------------ ------------------------- <br /> ..-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------- <br /> ------------- <br /> ------------------------------------------ <br /> --------------------------------------------------- ----------------------------------- --- <br /> ------------ <br /> - ---------- ------ ---------Date --- --- -•--------- <br /> Final Inspection by: --------- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />