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FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- --------------------- 53 <br /> (Complete in Triplicate) Permit No. <br /> _________________--_--_-___. This Permit Expires 1 Year From Date Issued Date Issued 6.­V7-4 i <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 <br /> ,,existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -------Z-71-9c,-JE--------kh-m-F------------- ------•--F CAIW-14_CENSUS TRACT -------6--------------- <br /> Owner's Name ------------bft2;v��-_--------H-NnLMAIBJ-------------------------------------------------------------Pho e <br /> Address ------ !2—.V'?--�- .�J A­f--`1M------ City <br /> SC <br /> a Q, <br /> Contractor's Name -_ -Va►'1 !_ �--------------------------------------------------------------License # ---- .--------------- Phone ------------------------------ <br /> Installation will serve: Residence 21�partment House❑ Commercial :❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--- --._ Number of bedrooms 3------Garbage Grinder Lot Size _t� _ �_�� ____-___---- <br /> Water Supply: Public System and name ----------------------•------------------------------------------------------------------------- -------------Private !� f <br /> _---:_Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑. Peat E] Sandy Loam (Clay Loam <br /> Hardpan Adobe '❑ Fill Material .ND----- if yes, type -.----.-----_-------------- y�, <br /> (Pl'ot 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,) \j <br /> ,) ' <br /> � i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ---------------------.----- <br /> Capacity ---- ----- ------- Type -------------------- Material------ ----------- No. Compartments ------------ -------- ` ^ ' <br /> V) � <br /> Distance„to nearest: Well ------------------°-----------------Foundation ---------------------- Prop. Line -----------•---------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ length of each line----------------------------- Total Length ----------------.-_-. ----- �I <br /> 'D' Box ------------ Type.Filter Material --------------------Depth Filter Material --------------------.----------------..:,._- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line, ------------------------ \, <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------- ------------ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth <br /> ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -...---. ----------.-- I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --_------------------------------1 <br /> . i <br /> Septic Tank (Specify,Requirements) ------------------------------:----------------------------------------------------- <br /> Disposal Field(Specify Requirementsl ---------- —D-p----------��------------I—EJ4C-14........L-----------5E-ZPl 6F------PJ7 <br /> -------- -9--X JZ- ----------------------------------------------------------------------------------_------------------------ <br /> -----------------------------------------------------------.-----------`__-'-•_'-.------ -------------------_-_-----.-------------------------.-----------------------------------------_---- -_----------- <br /> (Draw exi"ting and required addition on reverse side) I <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 liven- <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 beco a subject t r An's 'Compensation laws of California:" <br /> t ' <br /> Signed -- --------------=--------- <br /> Owner <br /> By ------ --- --------------------------- -------- --------------------------- itle ----- ------ --- <br /> -------------------------------------- <br /> (if other than owner) <br /> FOR D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------4--t ' Q--------- --------------------------------------------------------------- DATE -- 7` --------------- <br /> BUILDING PERMIT ISSUED --- ------------------ ----------DATE --------- -------------------------------- <br /> ADDITIONAL COMMENTS - --------------- - - ----- --------------------------- - l ------------------------------------------------------ --- -------------- <br /> --------------------------------------- - ------ -------------------- ---- ----- ---- - -- ------------------------ -- -- - <br /> ------------------------------------- -------- -- ---- ----�------- ----------------------- - ------ -------- <br /> ---------- -------------------------- ----- ----------------------- -------------- -- <br /> --- - - - --- -- --- --- ---- - <br /> Final Inspec io _ Date -- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M . <br />