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_ i t <br /> FOR OFFICE USE: r""'PI,ICATION FOR SANITATION PERA� <br /> 7.-----�------1(�•:.�_� Permit No. <br /> ` (Complete in Triplicate) t <br /> l � <br /> - sued <br /> ----------_----------------------------------___--------- This Permit Expires 1 Year From Date lssued3Miill <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 /> J013 ADDRESS/LOCA __._ &!L <br /> ___ <br /> awl <br /> CENSUS TRACT <br /> ------------------- <br /> Owner's Name -- --- -----------------C -! ------------------ ------ ---Pho----------------------------------------- <br /> (I," <br /> e <br /> Address FI ya_ �. re ------- City 't------------•-------- -------------- <br /> 31 <br /> Contractor's Name -----_--____ �- _.--------License #p? 17-3--.- Phone _�f� _�` ------------ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other--------------------- ---------------------- <br /> Number of living units;.... Number of bedrooms ____________Garbage Grinder _____________ Lot Size .,_/_5------__-___--_-______________- -, <br /> Water Supply: Public System and name -------------------------------------------------a•- ----------- <br /> t Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ 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'[ ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity -------#__-.------- Type -------------------- Material------------------ No. Compartments `U <br /> Distance)to nearest. Well ------------------------------------Foundation ------------------ -- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines _______________________ Length of each line--------------------------., Total Length ____________________________ <br /> 'D' Box _____::____ Type Filter Material --------------------Depth Filter Material ------._-__ <br /> --------------------------------- <br /> t <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _---_____.______-------_ <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 /> REPAIR/ADDITION(Prev. Sanitation Permit# ___-___ ------------------------------------------------- - Date -------------------•---•-----•----) <br /> SepticTank (Specify Requirements) ---- ----------------------- I--- -------------------=-----------------------•------- -- ------------------• --------------------------- <br /> Disposal Field (Specify Requirements) ..... .a�.--------ote-------------{v.- ���-------` ---------------------- <br /> ---------------------- ----------------- -- <br /> sr- <br /> r---------------------- - - --- <br /> - ---------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------------------------------- ------------------------ --------------------------- Owner <br /> BY ------------------------------------------------------------------------------------------------------- Title ------------------------ ---- <br /> [If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED iW ---- ------------------- --—U't(—-------------------------------------- ---- ­---------------- DATE ------------------- <br /> BUILDING PERMIT ISSUED ----------- --------- -----------------------------------------------------------------------DATE ------- -------------•-------------------•- <br /> ADDITIONAL COMMENTS ------------ � vn - <br /> -------- ------------------------------------ <br /> Final Inspection by: ----------------------- - xz= - - <br /> - - Date ��� b 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />