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fi FOR OFFICE USE: ,. <br /> . ' APPLICATION FOR SANITATION PERMIT <br /> k oma Permit No. -�-=-��_S. <br /> 3_ 3. :. (Complete in Triplicate) , <br /> r <br /> _ This Permit Expires 1 Year'From Date Iss 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 C unty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --._-._ f <br /> �j�j� -�1�- --------�-- --- - - ----- --- ---- - -- --------- --------- CENSUS TRACT ----- <br /> Owner's <br /> Owner's Name ----- f ! ------- ------- a-- = PhoneT63--".:3�� _ <br /> Address <br /> - --- f > _5City <br /> � City I- - - <br /> .--- <br /> Phane `6-^- d7Contractor's Name ............ <br /> - -� u -------------1 r7n"e #/_.� I <br /> Installation will serve: Residence Apartment Ho ❑ <br /> i <br /> Commercial,OTrailer Court !,❑ , <br /> Motel ❑Other - ----------------- <br /> r Number of living units:--.-/----- Number of bedrooms /-_-__Garbage Lo# Size _-.�__._?��z.S.............., <br /> Water Supply: Public System and name --------------------------------- = Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ `,Peat[] Sandq�,Loam Clay Loam "❑ <br /> r: <br /> Hardpan ❑ Adobes F ll Material ----- ------ if yes, type----------------------------, <br /> (Plot plan, showing size of lot, iocation of system in relation to\wells, buildings, etc. must be placed on reverse side.) <br />' NEW INSTALLATION: (No septic"tank or seepage pit permlifted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT SEPT <br /> { -------- <br /> I [ ] IC--TANK - --�-- Size`* <br /> _____ _______________.__.________ f,quid Depth ____,._.__________ ` <br /> Capacity --(----------------- Type ------------------ Material,-!-------------------- No. 'Compartments --'-------------------- <br /> Distance to nearest:.I,Well - ----------------------------------roundation -------- --I__------ Prop. Line --'-----------:.--.---- <br /> LEACHING LINE [ ] No. of Lines ____.____�`�- ___-_-- Length of each line._'_--______ _______ Tta) Length 1 <br /> # ------ <br /> ,, 'D' Box ----t------- Type"Filter Material ------------------�ept,h Filter Material -----------------------------------_-_------ <br /> j ## l t <br /> Distance to nearest: Well ----1___.____________-- Foundation_ ---------------------- Property Line ----_----•-----.---:.--- <br /> .. ,._._-.y�_ <br /> SEEPAGE PIT [ ] Depth ----- ------------- Diameter ________________ Number :___.____________-___ kock Filled Yes '❑ -No 0Water Table Depth ------------ Rok Size --------- <br /> ---------------------------------- r. <br /> ----------- <br /> Distance to]#nearest. Well ------------------------- <br /> ---------------Foundati�------------i------ Prop. Line .-� ------ ...... <br /> REPAIR/ADDITION(Prev. Sanitation!Permit# -=----- --- --------- ------------------- Date --------.---I------•--.___11 - <br /> -- ---- <br /> Septic Tank {Specify Requirements) y ---------------------------------------------------- i - = = <br /> Disposal Field (Specify Requirements) # <br /> : ' <br /> ---- ---- F i <br /> ---------------------------------------------------- - -------- <br /> Fi _ ._ _____ ____ ____._ <br /> ---------------_-------------------------------------___t__.___ _ __ .__________.____--.__.-_.-_______-_____ ------------------- <br /> {Draw existirSg and require addition on reverse sicf <br /> I hereby certify that I have prepaed this applicatio4r and►that-the-work will-be-done in accordance with San' Joaquin <br /> i 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." i <br /> Signed ' -----• - w- weer -,. <br /> BYr ------ Title - ------- � <br /> (if other owner) <br /> F R DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED' BY =. -------- ` ___._ _ �f o DATErZ- _ __1-7-6_ <br /> ______ <br /> BUILDING -PERMIT ISSUED ' h t .1�1 :. [- ..'.r..-.-----.------ <br /> __ <br /> --------------------- -----------------------DATE - ---------------,------;=----------------- <br /> ADDITIONAL COMMENTS <br /> a <br /> -----------------------"--------------------------------------- <br /> ----------------------------------- - --------- <br /> FinalInspection by: ----- -- ------------------ - Date ------- <br /> Final -- -= -- - -- - - __ _------_:--- - <br /> SAN J QUIN LOCAL HEALTH DISTRICT 6 <br /> E. H. 9 1-'68 Rev. 5M -_ <br />