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l <br /> i <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 176 -507 <br /> ------------------------- ------------ ------- <br /> ' {Complete in Triplicate) Permit No. ------- <br /> --------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is Fie�eby oracle to the San Joactiin Local Healthbistrict"fora pe m—it`to construct-and 'in'stall the work herein <br /> described. This application is made incompliancewith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIOt� k------------ ���1--------=---------------CENSUS TRACT -------------------------- <br /> Owner S Name -------------------------- ----- ------ -- ------Phone `(747-_Q_�r..7.3..- <br /> ress ------ ----- (- ---• ------ City <br /> � -------------------------------- ------ <br /> Add Contractor's Name -------------- --- -- ---- ---,J_0" ------:--------License #100.4_71------- Phone _li�! _-_74®7 <br /> i <br /> Installation will serve: Residence Apartment House'❑ Commercial ❑Trailer Court <br /> Motel ❑Other ------------------------------------ <br /> Number <br /> ------------- ---- - <br /> Number ' � J/ --' l ✓ <br /> of living units:__________ Number of bedrooms Garbag rin er _.____.____ Lot Size _-/_� ._X______O.1-.________ <br /> :., <br />' Water Su.PPfy:`Public System and name --------------------- - - ------••---------- -------=�----'------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet:j Sand'❑ Silt C] Clay ❑ Peat❑ Sandy Loam 0'! 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--Ke placed on Freverse side.) <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,)] <br /> PACKAGE TREATMENT { ] SEPTIC TANK'' ze----- F _ �'------------ Lig6iclDepth __S" ______________ <br /> Capacity 4*100-------4_ Type AJ______ Material- f -t .No. Compartments -_---�-*--------- <br /> Distance to nearest: VM1 ------------------------------------Foundation E- -- Prop. Line ---------_-� <br /> LEA_ <br /> CHING'LiNE '[ No. of Lines ________�1/________ Length of each line.___.__ .��� Total Length _1_17.0.-_�_._._.__ <br /> ' 1 f <br /> 'D' Box ----_.L�Type Filter Material,__,_ _ _ - ___.Depth Filter 'Material ---/if`-_T .. <br /> Distance to nearest: Wel! -----------------------*_ Foundation ----- Z -- Property Line _____S�_�'`_- _ <br /> SEEPAGE PIT Depth -------- {Diameter_ 6. r _... Number w_- -----Z----.--.�- Rock Filled Yes No 0 <br /> k <br /> '-----------------------------------------------Rock Size t / X �'� <br /> Water Table Depth �' s <br /> ! / ']� i <br /> Distance to nearest: Well _.-___________-______________________Foundation Prop. Line ___ 6--------- <br /> REPAIR/ADDITION(Prev. Sanitation Permi## --------_---------------------------------- Date -------------- C; <br /> Septic Tank (Specify Requirements) ----------- ------------------------------------------------------------------ i-------,---------------- ------- ----- <br /> Disposal <br /> . � Field (Specify Requirements) ...... <br /> ti. <br /> _ i <br /> ------------------------- - -----;------ -------`--------------------- -------------------------------------- <br /> -------------------- <br /> ------------=-------------- -- <br /> ----------------- <br /> -------- ---- -- --- - - - -- - -------- ------ <br /> Draw existing and required addition on reverse sid6y <br /> lrereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County,Ordmances, 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 /> "! certify that in the performance of the work for which this permit 1s issued;1 shall not employ any person in such manner <br /> as to becomeesubject to Workman's Compensation laws of California." <br /> /Signed ------ - -I----- <br /> -- <br /> - -------------------------------- Owner <br /> By ----- -- - ------------ Title -------{- __. -. <br /> -------------------------------------------------- <br /> o& <br /> --- ---------------------------`--._--.-�--_----- <br /> -- <br /> oeownery . <br /> r v. FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - --------------------------------------------------- ------ DATE ---77/--.7 ------------------ <br /> BUILDING <br /> -:/-_.7a------------------ <br /> BUILDING PERMIT ISSUEDI-----------------------s------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL <br /> --------- -------------------------------- <br /> ADDITIONALCOMMENTS ------------------------ --------------------------------------------------------------------- -------------------------------=--------------- ----------- 'v <br /> ---------------------- <br /> ------------ <br /> "� r+ ------------------------------------- <br /> _----- = = ------------------------------------ <br /> ! t i 1 �j+ ---'----------------------------- -- -- _ ---- <br /> Final Inspection by: ------------ -------__--- --------Date --- _ -- -.`T_U-----__ _-- <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT AV <br /> I s v -•q., <br /> E. H. 9 1-'68 Rev. 5M <br />