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`FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT S <br /> ---.._.._-—........................ Permit No. .........+ .._....._ <br /> (Complete in Triplicate) <br /> _...._...............I..........._._._ ....._...... �--1 6. 7V <br /> „... This Permit Expires 1 Year From Date Issuer! 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 <br /> County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ....I.O$PQ_... ..........................................................CENSUS TRACT ....................... <br /> Owner's Name ... ._._.................................................---•-......................---Phone ....................-............... <br /> Address ...............1 q- ,llr. o�sD -....._..........-........._....._,_.._ ......—. City ---- .......................................................... <br /> Contractor's Name ...............•--•---------------------.....•----•--------•---......-----_.....__..__..License # ........................ Phone .............................. <br /> Installation will serve: ResidenceAApartment House[] Commercial ❑Trailer Court C] <br /> Motel ❑`Other ---- �...... <br /> J <br /> Number of living units:..._...... Number of bedrooms 3........Garbage Grinder -- Lot Size ...- ..••-••-. ......... <br /> Water Supply: Public System and name ...............................................................................................................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand b Silt[] Clay ❑ Peat❑ Sandy Loam fZ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............ if yes,type ............................ <br /> (Plot plan, showing siie of lot, location ofsystem 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..........= .TYPe. --- .............. Material...................... No. Compartments ....................... <br /> Distance to nearest: Well :--Foundation .._ ___ ...... Prop. Line ..... 0 <br /> J ------- Q...---••-•-----•- <br /> LEACHING LINE No. of Lines _.____________________. Lenatli?.of each linea................._-_.------ Total Length ....................... <br /> D' Box ............ Type Filter Material.. ... ................Depth Filter Material ............._..------_--- -------._--__. <br /> L-4 <br /> j0istance to nearest: Well ...................}---. Foundation ..._...... ............. Property Line .....................- <br /> SEEPAGE PIT ( j Pepth� Rock Filled Yes ❑� <br /> ------•----•--_-.._. Diameter ................ Number __.._-----------..._..---- • ❑ No <br /> • Water Table Depth Rock Size <br /> Distance to nearest: Well ........................... .:.......Foundation .................... Prop. Line ......__. ............ <br /> AI DDlTIO Prev. Sanitation Permit# -_............................... ..v--- Date ------.... .................. <br /> % <br /> is pecify Requirements) ___________________ k <br /> Disposal Field (Specify Requirements) ....!3-1' - ` 1� --•• - •- --�-• • --- ••--•• <br /> LL <br /> �. r,x ---�--- <br /> -------------------------------------------------------------------------------------- -------------- ---------------------_.--_-----_,__---_.--.....- <br /> ji-Q ---, <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 subject Workman'sCompensation laws of California." <br /> Signed . ..... . ..._•.---•-•.................•----- Owner <br /> -- - --------------- Title ...............---...... --------------------•-- ---------- ....... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By .. ... - _.. .......................................---------------......-............... DATE ------ (!RAJ.14---------------- <br /> BUILDING PERMIT ISSUED ...C .._ .. . _ . ..............................DATE ............---•----------.-_-----.-.-.---- <br /> ADDITIONALCOMMENTS .....--------------------------------------------------------------•-••-----------................................................:---........................ <br /> .......... . ........... <br /> ....'... ....... ... <br /> ................. ..............................I------------------------- ..........-...............•........,................................ <br /> ......_.. <br /> Final Inspection by: . - ...................................... ..__._............ •• -----------Date <br /> SAN JOAQUIN "LOCAL HEALTH DISTRICT <br /> 3 241•'68 Rev. 5M -- 7/723 Ln <br />