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1.- FOR OFFICE USE: <br /> /_ �= 7 , <br /> APPLICATION FOR SANITATION PERMIT <br /> . ........ •_... <br /> (Complet in Triplicate} Permit No./7_.-..�fJ.�S <br />............................. ............................ <br />,..........r, <br /> This Permit Expires 1 Year From Date Issued Date lssuer :.�... <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIONGtd--`-_-� I ��..._._.-•--- .....................CENSUS TRACT ................_......... <br /> _ . .. � .. _ <br /> Owner's Name •---•-•--..-. .. _ �C1:�°l« _ �` 5 ' F - ...... Phonex. �.a .... ._:. <br /> f , ,. <br /> Address ._._.. l Gc>.c.. �._..i _3... .. :.. City.---• C,.. .1..:..�........:........... <br /> T17!�! <br /> - q` .... -Z- <br /> Contractor's Name ........ . . <br /> Installation will serve: Residence []Apartment House 0 Commercial []Trailer Court <br /> Motel ❑Other __.-__ ...... <br /> Water r I Public .. ^` f orboge Grinder ----.--• --- Lot Size ....�J.��!�Q... .......... <br /> Number of living units:.'---/_ Number of bedrooms G <br /> Supply: b c System and name ... .................................................... ................ ........................PrivateEr N'IN <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ 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 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 f ] Size../,4 ..911y..1y...................... Liquid Depth <br /> Capacity AP ......... Type Material '. No.' Compartments ._ _�........__ <br /> Distance to nearest: Well ____ ....................:.Foundation �!>___._.___ ._.. Prop. Line c .......... <br /> LEACHING LINE ( ] No, of Lines ------ _-------------- Length of each line.-_-/.._gq.f�................ Total Length <br /> 'D' Box ..�.__-•- Type Filter;Material '_�,�., Depth :Filter Material -------------=-------------- <br /> Distance to nearest: Well d. 0...........:. Foundation ._ :._...:_._.:. Property Line .-.7 z?V.. . . <br /> j <br /> SEEPAGE PIT [ ] Depth Diameter ..........:..... Number ......................_:._.__. Rock Filled Yes ❑ No {� <br /> Water Table Depth --------•........................................Rock Size ..------•-•-----••--•-- --- <br /> Distance to nearest: Well ........................................Foundation ----:--------------- Prop. kine -.._-___.._____._...... <br /> REPAIR/ADDITION(Prev. Sanitation.Permit# ..............................I.._.__...._.. Date ...................................I <br /> Septic Tank (Specify Requirements) --------------...............:........... ........................................--•---......._..... .............- <br /> % . <br /> DisposalField (Specify Requirements) ......:.............:..............-..............................----=---•----......_...---......---........._...----•--------------- <br /> ....................................................<-------------­--_; ---.......----•-•---------•- ---••••----•---•-------•-----••••---••---......--•-.._._....--•-'._...------.._...- -- <br /> ---------- --- <br /> (Draw existing and required addition on reverse side) J <br /> - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin I <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> zed agents signature certifies the following: <br /> "I certify that in the performance of the work for which Phis permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of Californi6:" " <br /> Signed ........... ....... .:.. .... •--•- -- ........ Owner <br /> BY .. ........ ........ Title ... �..._. <br /> (if other than own <br /> Fof DEPART NT USE ONLY <br /> APPLICATION ACCEPTED 8Y . .. .. ...... . - .. . f ..... <br /> . - - ......_I. ........... i <br /> BUILDING PERMIT ISSUED -__..: DATE <br /> ----- . .......................... •--••-•--•--••-•--. .__........ _ ................................... <br /> ADDITIONAL COMMENTS ......---•••......--••-•. .............................. ­---------- •-•--•-••-•••---- <br /> ... :............ ............................ <br /> -- f' .... ... ................................•-•• <br /> ........................... t7-. <br /> Final Inspection by: :.:::..:....:. ........ ... ..........................................Date <br /> SAN JOAQUIN LOC HEALTH DISTRICT <br /> 24 1-'68 Rev._5M' .. . _.. -. �_ .. 7 <br /> /72 3,X , <br />