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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> -- ---------------------------------------------- 7 5 <br /> (C-mplete in Triplicate) <br /> --------------------------------------- <br /> --------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ---.c <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 isJIM)_made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----W,------YRA R/Gp----------------------------------------- --CENSUS TRACT --------------- ---------- <br /> Owner's Name ---------------!7 E -------- ----- -------------------Phone _---------- <br /> Address ----------- gS ---�'Rl nlTA.d - City ---------------FeKtl''----------------------------------------•------ <br /> Contractor's Name ------------ - ---------------------------------- --------------------------------------License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence [Apartment House❑ Commercial [-]Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number <br /> ------------- ----------------------------Number of living units ----- Number of bedrooms -` --_.__Garbage Grinder _- Lot Size/0.4 ----------------------------------- <br /> Water Supply: Public System and name ------------------------------ --•----------------------------------- -----------------------•----------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand El 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 if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[*] Size-----------•----------------------- ------ Liquid Depth -------;----------------_ <br /> Capacity -/,AAQ4WTypeC*,%-r---- Material--- C1-------- No. Compartments --- _----------- <br /> 1 / / <br /> Distance to nearest: Well ------�?g_____----------------Foundation ------------_-.-------- Prop. Line --_— ----------- - <br /> de <br /> LEACHING LINE [ ] No. of Lines ------------3--------- Length of each line--------M ------------ Total Length <br /> ��Iu <br /> S'D' Box /1 --- Type Filter Material h�oclC:-------Depth Filter Material ----49---------- -------------.- -_--. l <br /> s.e / Itel Af <br /> Distance to nearest: Well J<-- --_--___ Foundation .--./0----------___ Property Line ------------------------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------------ --------------- Rock Filled Yes © No <br /> r <br /> WaterTable Depth ----------------- ------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -_-._-_-------_---. Prop. Line _----_-__._:..-_.._. p <br /> REPAIR/ADDITION(Prev. Sanitation Permit=# -------- ----------------------- Date -------•----------------------•---) �. <br /> SepticTank (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 /> "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'subj�e Wo 's Co cation Paws of California." <br /> Signed ��iZs� s Owner <br /> - ----------------------------------------------------------------------------- <br /> ------ 'Title --------------------- - --------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - ---------------- ------ DATE -------- --r3 --- ----1)------ --------- <br /> BUILDING PERMIT ISSUED ---------------------------------------- ------------------- -- <br /> --------------------------------------DATE ---------------------------------- ------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------ ---------------------------------------------------------=--------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------- ---------------------------- ---------------------------------------------- --- <br /> ------------------- ------------------------------------------- ------ <br /> ------- ---- <br /> ------ . _ -------------- <br /> Final Inspection by: --------------------------------- ---------------------------------- --------------------- Date ---- - <br /> SAN JOAQUIN LOCAL HEALTH DI RICT <br /> E. H. 9 1-'68 Rev. 5M r <br />