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- <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---- �-- -- � Permit No. --��--���/ <br /> (Complete in Triplicate) <br /> i17 <br /> t Date Issued - --`--5 <br /> ------ <br /> k __________________________________ _ _ _ <br /> _ __ ________ This Permit Expires 1 Year From Date Issued <br /> _ _ <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 ma'de in compli//ante with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ' __-----/�AV__r---_Ob%/t________________. -----------CENSUS TRACT ----S---t---­------- <br /> Owner's Name <br /> k (� �a�9� 0 ----------------------------------------------------------Phone <br /> Address ----------------------------------- ------------ City - 1 ------------- ---------------------------------- <br /> Contractor's Name __ Y.a-�_.--, L" ./2.Ctl` ---------------------------=--------License # - C �`� -_ Phone <br /> Installation will serve: Residence [�Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- ,��]]_ <br /> Number of living units..-.---./ _ <br /> ----'.Number of bedrooms _- - ---Garbage Grinder ----- ------ Lot Size Agi�:n'- ------------------ <br /> Water Supply: Public System and name ------------------------------------- ------------------- ---------------------------•-------------------.Private Rr <br /> I <br /> Character of soil_to a depth of_Veet: ,.Sand'[ Silt,❑ ,Gay ❑_. Peat(] . Sandy.Loam -❑- �Clay Loom .[]- <br /> Hardpan <br /> oam_❑_Hardpan ❑ Adobe❑ Fill Material If yes, type ---------------------------- <br /> (plot <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 /> 1 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 1< Size--- /1- w. -e-------_ Liquid Depth -_ -- -- -----_ <br /> Capacity /5-0-d-_--- Type �G�'°�Material��-"'_"'�_'- No. Compartments '_4.......... ... <br /> Distance to nearest: Well ------- - Foundation ..---f-Q-- '__ Prop. Line -_1S_- -:-_.---_. <br /> LEACHING LINE No. of Lines ___.r ---------------- Length of each line----ZIP.--------------- Total Length _-.._.-- <br /> iv <br /> •D' Box -_____-_---- Type Filter Material -�--o-Ck----Depth Filter Material ..--,f `--------------------•.•-•.•------ a <br /> I . f <br /> Distance to nearest: Well ----.-� --------- Foundation ----- -- ----------- Property Line, --�--------...:...- <br /> SEEPAGE PIT [ ] Depth -------- ------- Diameter ---------------- Number ---------------------------- Rock Filled Yes `❑ No i❑ 0 <br /> i Water Table Depth --------------------------------------- -------Rock Size ------------------------------ <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date --_---_---------_-------_._-_-_--) <br /> I } t <br /> SepticTank (Specify Requirements) -------- - ---------------------------------------------------------------------------------f-----------------�---------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------ <br /> ------------------G�r f n ----------------`------ -'-----•----------- <br /> 4 Y V=� <br /> ---------------------------------------------------------------------------------------------44---------------------------------------------------------------�------------------------- <br /> } (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 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 subject to Workman's Compensation laws of California." <br /> Signed n Owner <br /> t ----------------------- <br /> 1 BY a ,�f r ------------------ -Title --------------------------------------------------- ---- --------------- <br /> (If other than owner] <br /> I FOR DEPARTMENT USE ONLY <br /> 1 <br /> APPLICATION ACCEPTED BY -_ 1--F R' '-------------------------------------------------------------- ----- DATE --/~ -.7J ---- <br /> BUILDING PERMIT ISSUED ------- ------- ------------------------------------------- -------DATE - -- ----------------- , <br /> - i , <br /> ..�. ADDITIONAL COMMENTS -------- t ---------------------- --- --------- -- -------------------------------------------------------------------------------------- • ------------------------------------------------------------------------- <br /> ---� <br /> ---------- ------------- --------- ------ ---------------------- ---- ------- - -- --------------- <br /> --------------------------------------- ------ - ----------------------- -------- ---- ---- ------------------------------------------------------- ------------------- ?--/ <br /> - <br /> - --- - -- --- - <br /> - --- -- s-p---------------------- <br /> SAN <br /> .--.Date <br /> --- ---- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r �, H.'9 �1-'68,Rev. 5M <br /> � .. <br />