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FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> (Complete in Triplicate) <br /> Date issued _ 17i <br /> This Permit Expires 1 Year From date Issued <br /> -------------------A <br /> Application is hereby made,'toahe San Joaquin Local Health District for a permit to construct and install the work herein <br /> described: This--,application is madein-compliance-with CoupOrdinance-No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . l-3��.------- `-'�--- -- - --------------- CENSUS TRACT = <br /> --- <br /> Owner's Name" "- ----------- ------Phoney ' <br /> - - -------=----- ------ --- - --- <br /> - - --- <br /> I - ] --- '- - Cinse #� <br /> Address .--- - ---- ----- -- - -- •- <br /> .�� �G6� <br /> Contractor's Name Lic �l---- Phone ----------------------------- <br /> ------- _ ]. <br /> r <br /> Installation will serve: Res idence-E Apartment House 0Commerc+al ❑T.railer Court i❑ <br /> Motel ❑ Other I_--_ <br /> ---------------------- --------------- <br /> Number of living units:---- Number of bedrooms _--_ --__Garbage Grinder --------Lot_Size...____________________________________________ <br /> i I I., I " - ----Private's <br />—water Supply: Public System and name ------'---------= ------------------------------------------------------------------ <br /> Clay <br /> ----_---- ----- -- - <br /> Character of soil to a depth of 3 feet: Sand'❑ µS 1t:❑ "Clay ❑ Pe t`❑ r:Sandy,Loam ,❑ Clay Loam..O <br /> Hardpan ❑ t_Adobe Fill Material -___.---_- If yes,type ---------------------------- <br /> E tfti a <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must. be .placed on reverse side.) \ <br /> ,_ ! <br /> NEW;INSTALLATION: (No septicltank or seepage pit permitted if public sewer is available within 200 feet,] 1 V <br /> E <br /> PACKAGE TREATMENT {I SEPTIC TANK'[ ----Y- 'Size---------------------------------------- - Liquid Depth -------------------------- pq <br /> Capacity ` ` ype ' t-- <br /> No. Compartments .. <br /> - -- --- ----- Ma �1 <br /> i Distance to nearest: Well -----------f ----------------- ------Foundation ----------------------.Prop. Line ---__ .--.----.• <br /> LEACHING LINE r.{. J No:of Lines t_-----_----------------JLength of each line---------------------------- Total Length ----------- <br /> ----- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------•---------------•------- <br /> y Distance to nearest: Well:----- -------'------_--- Foundation -.--__---------------- Property Line. -____-__-----.-----=---- <br /> SEEPAGE PIT ( ] _ beptFi - l ___ Rock Filled Yes No <br /> i r <br /> - -------- - Diameter ---------------- Number ---------------------------- � <br /> \- -- j I i <br /> Water Table Depth ------------ -- ---------------- ----Rock Size -:------------------------------ <br /> "k _ Prop.t � ----------------......Foundation ---------------�- p. Line -----•-------=-------- <br /> I �e Distance to�Barest: Well `___-�-_--____._- ; <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit}# -------x-----�--------------------------- <br /> I <br /> ------ ------------------�" Date -__---t._.._-____--.--_---�-•---) <br /> t <br /> 5e tic Tank (Specify Re uirements) = F - 't <br /> Disp --------------- <br /> osal Field {Specify Requirements] _ ------ --= - -------------- -------- --- <br /> .. <br /> ! f s - ------ <br /> - <br /> i ? <br /> l I _(Draw existing and required addition on reverse side) <br /> liheI by certify that I have prepared this application and that th we ork,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: t <br /> "I certify that in the performance of the work for which this permit is rued, 1 shall not employ any person in such manner <br /> as to become subject to'Workman's Compensation laws of California." <br /> Signed --------- -------------------- -----=---- _ -----------------------Owner <br /> BY - --1 -- --- - ---- -- ----- - ----------------- Title -------------- --------------------------------------------------- <br /> (If oth an o �)-�' ; . # <br /> _-''FQR DEPARTMENT U NLY <br /> APPLICATION ACCEPTED BY ------'' .--------------------- ---------- ----- ----- DATE ---&-------q-63------------------ <br /> BUILDINGPERMIT ISSUED ---- --------------- ------ �` ° ---- ------------- - -- --- -------------- ------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS __Z--------------------------- - -- t, + ' <br /> .r ------------------- ------------ ----- ------------------- ------------ <br /> ----------------------- ------------------------------------------- ---------------------- -------------------------- ------------------------ <br /> - ! - ---- ---- ------- ----------------------------- ---------- <br /> I --------- <br /> - - <br /> --------------------------------------------- ----------------_--------------------------------- - f <br /> --fz--_� <br /> Final Inspection by: ------ -- ---------------------------------------------- ------ --- --- ---- ----- --.Date --------------- <br /> ---- <br /> µ T SAN JOAQU CAL HE _ Tbt TRICT <br /> E. H. 9 1-'68 Rev, 5M <br />