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1 <br /> FOR OFFICE USE: i <br /> APPLICATION FOR'SANITATION PERMIT 7Z �f <br /> Permit No. <br /> • -n (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued __°3 <br /> --_------_------_-----------------__-__----_-_---- # I <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 /> JOB ADDRESS/LOCATION __- ---J--z- ----`----'- ---- - --- -- - a_ --------------CENSUS TRACT -------------------_ -__- <br /> / - - j hone <br /> _t�------------------ <br /> Owner's Name -----------C_-4--- I--f-•---- <br /> :74- <br /> s _ _ - UAddres ----------------------- ---------------------------------------------- y <br /> Contractor's Name ----------------------------------------------------------------------------------------License # -------- --------------- Phone _.--------------------------- <br /> Installation will serve: Residences Apartment House'❑ Commercial;❑Trailer Court ❑ �- <br /> r Motel ❑ Other ------------------------------------------- 3 E <br /> Number of living units:_________ Number of bedrooms --- Grinder __ _---_ Lot Size ---- ------ 4- _._-________ # <br /> Water Supply: Public System and name --------------------------------•---------------------------------- --------------- --•-••- '--------Private ❑ <br /> Character of soil to a depth of 3 feet: $and'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam•❑ Clay Loam <br /> ' ' Hardpan Adobe Fill Material ------------if yes;type ---------------------------- <br /> r� <br /> {Plot plan, showing size of lot, location of system in relation,to,welIs, buildings,. etc. must be placed on reverse side.) GV; <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted.if:public sewerisv�ailable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.k 11 Size____ - _y L'Liquid .Depth ----------- Z._-------- L <br /> Capacity _f. _! ___ Type�r,C___ =__. ateria!__ -+2i�- a. Compartments <br /> ---------- <br /> L <br /> Distance to nearest: Well ------------------------------------Foundation --j------------------ Prop. Line ----------- <br /> ------------ <br /> LEACHING LINE [[y]�No. of Lines ______ _ ___ _ ______ Length of each line-------- _____________ Total Length :___ 5--------------- <br /> 'D' <br /> -_--•.__'D' Box ------------ Type Filter Material -------------7""Depth Filter Material --------------------------------_-------- <br /> Distance to nearest: Well --------------------_____ Foundation ------------------------ Property Line ___-___-__------__-:____ <br /> SEEPAGE PIT [ ] ( Depth ____ -------------- Diameter ------------A__ Number ___________________________ Rock Filled Yes ❑ No i0 <br /> F � -----------------------------------------f <br /> c Water Table Depth ---- --`.- Rock Size --------------------------- <br /> Distance <br /> ---------------------- --Distance to nearest: Well ` <br /> F -- -- -----_-_-_-_________ ------------­---- <br /> R____C_1______-_/_____/__S._�-_-_Foundation _fL_;___=__ `_ ___�_�)P <br /> rop. Line __fi_ <br /> -_____._____y__-_-__ <br /> . <br /> I - <br /> r <br /> REPAIR/ADDITION(Prrev. SanitationPermit# _ - N <br /> ________ ____ _____________ Date <br /> .k;._____._______ __._______________ <br /> stpeqer ---- ------- ---- _ - - <br /> _ <br /> ic Tank <br /> DPosal Field (Specify- Req•uieRequirements) <br /> ----- --------- z <br /> ------------------ =r� �a•: 4n3. 5 �`'rr�d <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. Son 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 shalt not employ any person in such manner <br /> as to become subject to W rkman's Covapenscition. laws of California.'.' 1 <br /> Signe ---------------------- ------ ---- /. <br /> BY -=------------- --------------------------- ---------- ------------ --1 -- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 7- d DATE ----- —-----7-•_7-.2_; <br /> BUILDING PERMIT ISSUED / # D. ATE <br /> -_ <br /> ADDITIONAL COMMENTS 3 -- -------- --------------------------=---------------�'-u ���- ------ ------ -----_ <br /> -------------------------------------------------------- -------------------------------------------=-------------------------------------------- ---------------------------------------------------- <br /> -i; <br /> r <br /> -------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------- <br /> inalInspection by: ------------------------ -------------------------------------------------------------------------------------------- --------------------------------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />