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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. _. 5..;.;3 S <br /> IComplete In Triplicate) _ <br /> d I <br /> Date Issued <br /> This Permit Expires t Year From Date Issued Da <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ......� . ���Qi .�...................... <br /> �- ------• ...........................CENSUS TRACT .......................... <br /> Owner's Name .­C./.V --..... Bf3oel.TJX..,ev...................r --•............-................ <br /> Address . ... `�Q . <br /> _. Phane . <br /> " . <br /> ..........-------.... r <br /> Contractor's Name ----- �.__ �._.-•----• --• •-•-•..........................•-•-----•---.License #c;2eb:,.r'`. .a2-.. Phone �...�.%..�. <br /> Installation will serve: Residence VApartment House C] Commercial❑Trailer Court ❑ <br /> Motel ❑Other.................................••......... G <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 0 Silt❑ Clay ❑ Peat❑ Sandy Loam N Clay Loam ❑ <br /> Hardpan❑ Adobe fl 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...'�Z �`~�---Sf" ............ Liquid Depth .......................... <br /> Capacity _� - __-- Type JO,!I° ---.-5.".45 Material.--..__.-......•...... No. Compartments -•---• <br /> .I........... <br /> f / /y <br /> Distance to nearest: Well _.117d....................•-----Founda#ion fes............. Prop. Line : ---•.........� <br /> LEACHING LINE ] No. of Eines .. _, .- length of each line..__ <br /> .- -----• -•--�............... Total Length ...rte/.�'...........� <br /> 'D' <br /> �� <br /> Bax ..__.�'_... Type Filter Material .4/-�Y,�„ <br /> _ yDepth .Filter Material ......,�-;� ...........................0 <br /> si 0 <br /> Distance to nearest: Well _. A............. Foundation --",O_.__...-___._- Property Line ..5................. <br /> SEEPAGE PIT [ ) Depth ------- ------------ Diameter ................ Number __.__•...... --------------- Rock Filled Yes ❑ No � <br /> .� .�.. Water Table Depth -. -------•------------- -- -------------------Rock Size ..........--•............ •---•- � <br /> Distance to nearest: Well ...........••-•-----------•.............Foundation --- ................ Prop. Line <br /> .... •---.....--_-- -•--; <br /> ...... <br /> REAIR 7DDkION{Prev. Sanitation Permit # ----.- .•---------------- D ................Vt.------------ -------- <br /> Septic <br /> (Specify Requirements) <br /> Disposal Field (Specify Requirementsl ----------------------------------=---•--..............................- . �...:.... <br /> --------------- ------- <br /> ----;-• --_-------------------- ----------------•---:-- ..................................I.............. <br /> (Draw existing and required..additiori-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 Joaquln Local Health.District. Horne owner or licen- <br /> sed agents signature certifies the following: f ! <br /> "I certify that In the performance of the work for which tbis'permit is issued, I shall not employ any person In such manner <br /> as to become subject to man's Compensation laws of California." I I <br /> Signed .`Ar *._. _ ��'� <br /> k Owner ; <br /> BY----- •-------r-------4• <br /> - 7itie - .---- <br /> (If other than owner) <br /> OR �< <br /> DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY -.• � -V-- ...I................t.-------------------....-._...----------------­----- DATE. <br /> BUILDING PERMIT ISSUED .- 4 -- ..............DATE ................ ------....-..:::....: ...:. <br /> ADDITIONAL COMMENTS ----- -•--•-•------•------------------ <br /> ---------------------- -- ..................... <br /> _.... <br /> ---------------­-------- � :�:..._ -------•-------------------•----- •---------•------------- •-----........ --.... ......... ------.....---•--• <br /> ...............•----••----...-•--•----• --•--- ------•------- . <br /> Final Inspection by: . �_�_ . _-�-- ��--------------•-- -- -• •--•-•- ..Date .s"-/�''�..._ <br /> EH 13 2a 1-68 I -V. 51 j SAN JOAQUIN LOCAL HEALTH DISTRICT 3M <br />