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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .........��171---------------- ?.'_a---- r Permit No:_.7 -_ . <br /> (Complete in Triplicate) <br /> "* Date Issued <br /> _- ` '"°"""`This:Permit Expires i Year From Date Issued <br /> 1 <br /> ' Application is hereby made to the San Joaquin Local Health District ,fora permit to construct and install the work herein <br /> described. This application is made in com <br /> pliance <br /> y�with County Ordinance No. 549 and existing Rules and Regulations: <br /> ' JOB ADDRESS/LOCATION/ �Q -- '-:-��.�c--- - -------- ---------- --- ...... <br /> ' _ '`_ CENSUS TRACT ._ <br /> Owner's Name '` ' ..... , ----------- -Phone ----------------------------- ------ <br /> 71 "—__----- -------------- <br /> ', Address ---- ----'--------Y.7 . A4�--- City -- -- '----'`f--------------------- i <br /> a <br /> Contractor's Name -- � - --/ --------------------___--___ .License # _ � _ -- Phone --- - /----- <br /> Installation will serve: Res idence,KApartment House;`Commercial ❑Trac er Court 10 <br /> Motel ❑ Other -------------------------------------------- i <br /> r Number of living units:________ Number of bedrooms ___+ _ <br /> Garbage Grinder ._ ___ �� ,�' _�` - <br /> _ Lot Size <br /> { Water Supply: Public System and name -------------- --------------------------------------------------------------------------------------- ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay:Lcam ❑ <br /> y Hardpan ❑ ; Adobe Fill Material ____________ If yes,type --------------I- ---------- <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'[ ] 4 Size------------------------------I----------------- Liquid Depth ---------------- <br /> F <br /> --------------- -,___-- <br /> Capacity #s_____- T '- _ __7Material---------------------- No. Compartments __________._..__:.___ <br /> P Y YP.e` P <br /> LEACX , ` Distance to nearest. WLS11 __1_____________T""y­Foundation -- -------------- Prop. Line __________-_---_-__._ <br /> HING LINE [ ] No. of Lines -------- ____..Length of each line------------- Total Length -----------.______________-- <br /> i <br /> { 'D' Box ----_._ ---- Type Filter Material --------------------Depth Filter Material <br /> 1 r <br /> I Distance to nearest: Well _________________________ Foundation ______---____- ... <br /> ---------- Property'Line Line .--- �-•------•---•----- <br /> SEEPAGE PIT Depth -------- Diameter --� 7 _____ Number ________ ______________ Rock Filled Yes,& No ,O <br /> Water Table -Depth -------------------f------------------------Rock Size ------------I---r__-_-- I <br /> Foundation ---/___4__----_--- Prop. Line ___________.�--.-_. <br /> 1 Distance to n�arest: Well-___-Z�d�--_-__--____ - <br /> REPAIR/ADDITION(Prev. Sanitation Permit S# -------- ___________________________________ Date _____- _--__.___-.•.__.___________) <br /> t <br /> Septic-Tank (Specify Requirements) . <br /> --------------e--------------------- rr----------------------------------� <br /> ---------------- -------- <br /> --- <br /> Disposal Field (Specify Requirements) -----1 � - ✓ A-4,ea--- ------ <br /> `{S` - <br /> ------------------------------------------------------------------------------`--------------------------------------------------------------------- <br /> F -------------------------7--------------------- -- - --.------------------------------------------m----------------------------------------------------------- --------------------------------- <br /> r+ (Draw existing and required addition on reverse side) <br /> I hereby certifyfthat 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: } Y <br /> "1 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 /> F I 1T x- <br /> i Signed ----- - ---"----------------------------------------------- Owner <br /> B ) } <br /> Y `--- 7i#le ------- '{' <br /> ----------------- --- --- <br /> .(If other than owner <br /> FPR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------- ------------ DATE -- --- -- -----_---_- 'rV=.71 <br /> BUILDING PERMIT ISSUED / ------- ---------DATE --------------------------------- - <br /> ADDITIONALCOMMENTS - - -- - - - ----------------------------------------------------------------------------------------------------------•------------------ <br /> -------------------------------------------------------------------------------------------- --- 1��� <br /> {----------- f <br /> Find Inspection by -- --------- --------- ---- -------- -------.Date ---- ' =- <br /> ` <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> � <br /> E. H. 9 1-'68 Rev. 5M <br />