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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> a <br /> ------------- <br /> --------- r Permit No: <br /> i (Complete in Triplicate) <br /> ---------------------------------------------------------- <br /> _--_-____--_--- This Permit Expires 1 Year From Date Issuer! Date Issued <br /> Applicat ion is her eby mad e 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 --------- / ( ; / �� T� it� CENSUS TRACT <br /> Owner's Name ------ Qt -/ — f ,1 - Phone . . <br /> / ' <br /> Address .�Q-�j7�`---- ----5i-------�41�C�1----------------------------- --------•--• City __?�i� ?---� -/Y��.....--•-------•------ <br /> Contractor's Name ---- _i ._ - L ..__________________________________ ___License # 2 Phone <br /> Installation will serve: Residence V Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------s--�------------------- ------ <br /> Number of living units:_________ Number of bedrooms ___T-_ Garbage Grinder _-_______ Lot Size ---___________________________ ___________ <br /> i i <br /> Water Supply: Public System and name ------------------------------t--------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam'E] <br /> Hardpan ❑ Adobet Fill Material ------------ If yes,type __________________-___-___ <br /> (Piot 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 ktank or seepage pit permitted if public sewer is available within 20.0 feet,) <br /> l' <br /> PACKAGE TREATMENT [ ] SEPTI CTANK f ] Size_- Liquid Depth -----------_______________ <br /> Capacity p � Material------__ _ <br /> P Y / f�-- 7YPe��/-- � - ------------ N�. Compartments ��y--•------------ <br /> 'd .�.� <br /> Distance to nearest: Well _. --------- -- ------------Foundation/D.__.___'_._____ Prop. Line_____________ <br /> LEACHING LINE ' [ ] No. of Lines __3----_----------- Length of each line..... ---.-----"Total Length_," __________:_ 0-3'D' Box __/_.____ Type Filter Material L.y___ _Depth Filter Material -'_ ____------_------_______________ _ <br /> Distance to nearest: Well __ tea__ Foundation C�_/---------- "PropertytLine. __6--1_ ..____.____. LA <br /> SEEPAGE PIT [ ] Depth ___ --------------- Diameter ________________ Number ------------------------"___ Rock Filled Yes ❑ No C3 d <br /> Water ------ <br /> -- <br /> ---- <br /> ,Table Depth ------------------------------------------------Rock Size ------------ -- - ----- S <br /> , -.. A. .r- 4 <br /> f ) Distance to nearest:Well..._=------------=----- -==------__==-Foundat.ion --------------- Prop. Line -----;......... <br /> ...:_- <br /> .. <br /> REPAIR/ADDITION(Prev. Sanitation" Permit# ____________________________________ ______ Date ------ --------------------- ----- <br /> Septic <br /> ___ y�F <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------- ------ ---------•--------- ----------------- <br /> 41....�...._-..,..., -� ,._-._ �...w.x.,...m.,.. �... �._.�. ri.y.., i <br /> Disposal iField (Specify Requirements) ------------- --------------------------------------------------------------------- --------------------------`----------------- <br /> -- ,. -- _ - -------- ------------------------ <br /> --------- <br /> --- -------------- <br /> y --------------------------------------------------------------- -------- <br /> hereby certify--------------------- i _ <br /> (Draw existing and required addition on reverse side) a <br /> rtify 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: j - --�---v <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 sub'e to rkm n Com ensati.on laws of California. <br /> ' t <br /> i p <br /> Signed ----- _ _._ _ _ Owner <br /> tBy ---------------------------------------------------t---------------------- t ------- Title ------------------------------------------------------------------------ <br /> (If other than owner) ) <br />{ j <br /> FOR,DEPARTME T USE ONLY 1 <br /> r APPLICATION ACCEPTED BY ---- -' -- ----------------- DATE -.-1-`-t�774-------- <br /> BUILDING PERMIT ISSUED -------_-_ ____-- " _DATE -------------------------`-----------------. <br /> ------------ = <br /> ----------------- ------ ---------------- ------- <br /> ADDITIONAL COMMENTS -----:'---------- --------------- - --- --- ----- ------=--------•=----------------- <br /> i� ; <br />� ________________________________________________ __-__________________ --------------------------------------.1------------ _---------------__.----------------- <br /> - -------------- ------------------------------------ <br /> _________._______________________________________________________ __________ __.____._____ ________.____.__-._-__._--._.______________.__________ _ <br /> _______________________________.______ ---- -------- _ _ <br /> - --------------------- <br /> - <br /> -------------- <br /> __. <br /> Final...Inspect.ion-by:- --- ----- -- ---- --- :T_T_._- - :.aDate <br /> SAN JOAQU LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M r <br />