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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> "------ - <br /> (Complete in Triplicate) Permit No. _7_1 <br /> -----------41jW---i....... -------------- This Permit Expires f Year From Date Issued Date Issued -- 3----73 <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 -- I/O�------ �I , -----j -----------------------------CENSUS TRACT ----- ---. - -.- <br /> Owner's Name ---------7- --tom X--6-/Va--Z--------------------------------- ----------------------- ---Phone.ko'- 3 437`_2fa_ <br /> Address ------- --AL1--- --'Zov/��------1W_ _4l ----------------- City - /Vi4✓1/ `� ------------------------------- •-•-••--- <br /> Contractor's Name ----, ,fi ------FO/64/1,97Z,. -----------------------------License # - _ Phone 1 Vo- I <br /> Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:----- Number of bedrooms ---3----_Garbage Grinder ------------ Lot Size ---l —---------------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------------•-----------------------------------Private <br /> __.,Character,ofrsoi!_to_a depth of 3.feet:= Sand'❑. Silt❑ Clay.❑Peat❑._._.Sandy_LooM X_� lay�Loam i❑ <br /> Hardpan ❑ Adobe 'D 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.) jj <br /> NEW INSTALLATION: (No septic tank or seepag6pit permitted if public sewer is available within 200 feet,) <br /> � <br /> PACKAGE TREATMENT { SEPTIC TANK! Size----6-X-05 °4._ ,.X ---------- Liquid Depth --- C5----1 I------ p <br /> Capacity j _dP'v Type � EG.4S/ Material---------------------- No. Compartments O- <br /> stance to nearest: Well ___- O----------------------Foundation -- ----_----_ Prop. Line ----------------------- <br /> LEACHING <br /> _--_-_G-.._-.-.- �t <br /> LEACHING LINE No, of Lines --- - Length of each line------(�1 -._----.----.- Total Length .--------­---------------- <br /> 'D' <br /> .'7d----_- <br /> - --- - y ----- <br /> D' Box ___ Type Filter Materials _Depth Filter Material ------ _ <br /> Distance to nearest: Well ----5G-_-_--.--_. Foundation ____V;0_ ........ Property Line ------------------------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No rL <br /> Water Table Depth ----------------------------------------.-......Rock Size -------------------------------- <br /> Distance to nearest: Well --------------------•------------------.Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -----------------------...........) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------------------------•----------- <br /> Disposal Field (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 /> "I 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 subjectjo Workman' Compensation laws of California." <br /> Signed ----- �- ----`-=- -------------------------- ------------------ Owner <br /> By ------------ ----- -------------------------------- -------------------------------------------------- Title -------------- ---------------------------- ------- --- ------ ' <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- '------------------------------------------------------------------------------ DATE ----- -------- <br /> BUILDING PERMIT ISSUED ---------------------- -------------------------DATE ----- --------- --------------------------- <br /> ADDITIONALCOMMENTS --------------- -------------------------------------------------••--------- --------------------------------- <br /> ---------------------- <br /> --- -----------------------•----------------------------- ----•--•--- <br /> ---------------- -- - ------ ----------- - -------- ------ <br /> Final _� �--�` <br /> ----------------------------------.--------------- ---------- <br /> - - <br /> lnspection -Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> m <br /> E. H. 9 1-'68 Rev. 5M <br />