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- 1 <br /> FSR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----- <br /> ^ (Complete in Triplicate) Permit No _____________________ <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued _Gs/.0--71 <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 comp_UarWewith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . -----/--_ ----` _-.-,-. _ ¢^!_ - -- -- -- -- -------------------------------.CENSUS TRACT .......................... <br /> Owner's Name -- -----------------------------------------------------Phone --- `7 f1.---- Z3 <br /> ------------------- ------ -- <br /> Address --------------------------- (Y-i ---------------•--- City --- '---------------------------------•------ <br /> Contractor's Name !` 2 --'�__' s�—_� �-License # ________________________ Phone <br /> Installation will serve: Residence AApartment House❑ Commercial ❑Trailer Court !❑ <br /> n Motel Other -------------------------------------------- <br /> Number of living units:--------- Number of bedrooms ___Garbage Grinder _-_ ___-_ Lot Size 1f 2-,J-C <br /> Water Supply: Public System and name --------------------- - _---------------- --------- _`_-"_--- PrivateEl <br /> of soil to a depth of 3 feet: Sand❑ Silt E] Cla ❑ 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 p Size-------4'�_JL__b.__---------------------- Liquid Depth .__...._•� <br /> Capacity L;_P_v---- Type l -- Material_01a, _ No. Compartments .-! ______________ i <br /> Distance to nearest: Well �_ ____________________Foundation ___ �__ ___ "`� <br /> ,,// __ Prop. Line __o�-.C?.____.__._ <br /> LEACHING LINE A No. of Lines ----Z_______________ Length of each line-_-._.0 _0--__----___ Total Length ---I_.2-0..`. � <br /> D' Box ...�______ Type Filter Materia __ ...Depth Filter Material ---�_�.._._... <br /> Distanceto <br /> rneearest: Well Zal -.____-_- Foundation _____/f_�_____._:_ Property Line _____--..._:-•--•_ <br /> SEEPAGE PIT Depth _c2_Nl___�----- Diameter __ T-4--) Number ___ -- Rock Filled Yes No i❑ <br /> ----- <br /> Water Table Depth --- J --'?�'___________________________Rock Size ___.___._. <br /> Distance to nearest: Well ----/�{t_,_____ ___-_--- <br /> __________•-_-----Foundation _-�___. <br /> � -- Prop. Line ----------------------r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _______________-__••_____________) N <br /> SepticTan (Specify Requirements) ----------------------------------------------------------------------•---------------------•------------------ --------------------•- 7 <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 su�t to Workman's mpensation I ws of California." <br /> Signed s_ -LT --- ------------ O'�c- / <br /> BY - ------- ---------- - Title . _2 <br /> --- - ------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPAR ENT USE ONLY <br /> 102 <br /> APPLICATION ACCEPTED BY ------ -- -------- --------------------------------- DATE - — <br /> BUILDING PERMIT ISSUED ---- ----- - - �- DATE -----------------------m----------------------------------------- ----- <br /> ADDITIONAL COMMENTS __. C�C�vf_______________ _ _ _____ ..-. �f�------ _ _'y ----------------------------- <br /> ------------ ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------- --------------------------------------------_-----'--------'/------------------------------------------------------------------------------------------ <br /> ---------------------------------------------- ------------ - - - - ---------------L�-�Z' <br /> =--------- ----- - <br /> Final Inspection by - --------- - Date ,-.'` . <br /> 4 <br /> SAN JOAQUI ' LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />