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. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ..................... <br /> ..... .This Permit Expires I Year From Date Issued Dote Issued ......`............. <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 DDRESS/LOCATION .....1;;;k. .. f.V.t./�`�--•---........�4. .......................CENSUS TRACT ......... ...... <br /> Owner's Name .._.._.....p.....:�'.�2�...1_�..�._----•---.�._I�•U•�...1.�:_:�..�.......:.............f......Phone.�.3�'- -•- -• -- •--... <br /> Address --- ..__.... J=-0 [347--x-- -_..._� �= City ../.4..................................................... <br /> ....... ........... <br /> �_� �.: ---.License # Phone _ ` . • <br /> Contractor's Name �..�.._. .D__�---�....................... ------- .........--------•. <br /> Installation will serve: Residence (g Apartment House❑ Commercial ❑Trailer'Court .-❑ <br /> Motel ❑Other----------------------------------------•••- / <br /> Number of living units:... .Number of bedrooms ..A....Garboge Grinder y _ Lot Size ....f f g�LT,� 'i.r................ <br /> Water Supply: Public System and name ................................••---.............------........................................................Private [� <br /> Character of soil to a depth of 3 feet: Sand:❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 'Clay Loam ❑ <br /> 'Hardpan [:] ' Adobe ❑ Fill Material ............ If yes,-type ..-_------__------------ <br /> (plot <br /> :----- _------------{Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.1 <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---------------------- kNo. .Compartments ....................... <br /> Distance to nearest: Well :...................................Foundation ...................... Prop. Line :..... ............ <br /> LEACHING LINE ] No. of Lines ------------------------ Length of each lins............................. Total Length ........-....._---__......._...1� <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ......................................--__.Q <br /> --- Foundation $ Pro Line .............. <br /> Distance to nearest• Well ..............•-----_--- . party --._...._.� <br /> SEEPAGE PIT ( j Depth .................... Diameter _.._... Rock Filled Yes , No <br /> ...._-•---••--__ Number ..................... C] Q� <br /> Water Table Depth ...............Rock Size <br /> Distance to nearest: Well ...............:........................Foundation ............-:__-.:. Prop. Line ----_______-__--------C" <br /> REPAIR/ADDITION(Prey: Sanitation Permit# ............ Date ___I A <br /> Septic Tank ISpecify Requirements) _----------------........ _.... t ------- ----._ .: ............__... <br /> r i <br /> Disposal Field (Specify Requirements) ....... _ ---------!!' --------------- <br /> *� <br /> :._ <br /> �G <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 to Workman's Compensation laws of California." <br /> Signed ...;0--•-------------------=-------------•-•- ..._._.........:--•-•••--•-•. .......-•-•••--------- Owner <br /> 4 <br /> By ..__... � f ' ' ! . title ... .................................. <br /> t If other than owner) <br /> fpRZOPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By ...../,It 17 ..........................__.................... DATE � <br /> BUILDING PERMIT ISSUED ........................ <br /> ......:.......................•..............................................--------DATE ......................................... <br /> ADDITIONAL COMMENTS <br /> .................. -•- ------•. ------•• --------------------•-- . ...................................-_.-.............................•--••._................. t <br /> ....................................................... ......................... --- •------------------•-•----.:......................__..----------••--••................-----------_..... <br /> 1 <br /> ----------------------- ---------•......... ••------..._........ .............. <br /> Final inspection,by: ....: i __ <br /> .��-•-• �• - --------•--•---•........................................................... ate . �.l-.�s5�.--- <br /> .� ...'SAN.JOAQUIN LOCAL HEALTH DISTRICT <br /> 4/77 3 M <br />