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t FPR OFFICE USE. APPLICATION FOR SANITATION PERMIT ll <br /> - 9 <br />�>,�--- ----- - - ---- --------- - � -------------- Permit No. ------------------!_. <br /> ��. - �•��.----- �.��#� -��� (Complete in Triplicate) O ,[ <br /> Date Issued Q� 17. <br /> --------------------------------------------------- This Permit Expires 1 Year From Date Issued <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 com fiance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ,i <br /> JOB ADDRESS/LOC ION ._ f y`/�C ------------------------ ---------------CENSUS TRACT ---X6---------------- <br /> ZOwner's Name Qjl'� � ems: Phone ------------------------------ <br /> Address - - ------ - -- ----------------=--- ------------------------------------------ <br /> --------- <br /> ------ -------------------------- .. City ---------------------------- <br /> Contractor's Name License # -- - --~ Phone <br /> Installation will serve: Reside nceXApa rtm e nt House ❑ Commercial ❑Trailer Court i❑ <br /> 1 <br /> Motel F1 Other ---------------------------------------- <br /> Number of living units:________ Number of bedrooms --------Garbage Grinder ------ Lot Size/,2Z_ A- / f <br /> _- "". - -------------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------•--------.Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat ❑ Sandy Loam ❑ Clay Loam , <br /> t <br /> 3 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 se is tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK'[ ] Size----------------- <br /> '------- Liquid Depth ---- -- ._-,----- <br /> CapacitYly�, �g-a---- TYP6,1_�_r Material------------- -------- Nole. Compartments ------------- ------ <br /> E <br /> Distance to nearest. -_--_�_____________________Foundation __ �}-.--____ op. Line ______{ __.___.__ <br /> LEACHING LINE VNo. of Lines --•-- ----------- --- Length of each line-- -- ---- -- -� >-- Total 'Length .---- - ----------- <br /> 1i iI <br /> `D' Box ___�. Type Filter Material. �a_G� -;Depth Filter Material ___ -__ <br /> f ------ <br /> 71 <br /> Distance to nearest: Well _____ __-"-----_____ Foundation ______t0___.___-`-_ Property Line, _.-------Gr-.____._.__. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter---------------- Number _-_.____{�______________- Rock Filled Yes ❑ No O , <br /> Water Table Depth'---- --- f > <br /> -- ---- =-------------------------Rock Size -------------------------------- <br /> ' <br /> Distance to nearest: Well ----------`____'----------------'-------Foundation _________________ Prop. Line _...___________-_____. <br /> REPAIR./ADDITION(Prev. Sanitation Permit# __'__-- -_.-----a-—------ <br /> bate,. <br /> *, _ -- ate:'"'�i <br /> `--- <br /> Septic Tank (Specify Requirements) ------------______---- - ----�--k- <br /> - <br /> ---'-"--�-"-"----"------+�--}- <br /> ------------------------------ <br /> ' t-' <br /> Disposal Field (Specify Requirements) --- -------------------------------------------------- <br /> t <br /> A y <br /> y <br /> S t � 4 <br /> --------------------------------- <br /> --------------- ----------------- --- -'------ ------------------------- -- ----- -- ------------------- --`---- --- - <br /> r <br /> (Draw existing and required addition on°reverse side) fi <br /> I hereby certify that 1 have prepared this application and that the work will'be"clone in accordance with San Joaquin ' <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin L co al Health Dlslrict. Home owner or licen- <br /> sed agents signature certifies the following:-- ----- —__ 1 -- -. — I-r• <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 becomuWec# to Workma Compensation laws of California."A ' <br /> Signed '` �$ ---- Owner <br /> By = ---- ------------------------------ Title <br /> .t <br /> (If other than owner) "I ''*1 <br /> "PARTMENT USE ONLY--- <br /> APPLICATION <br /> NLY'"—APPLICATION ACCEPTED BY -------- - <br /> ----------------•---------------- -----------------------. DATE -------------- <br /> BUILDING PERMIT ISSUED -------- ---- ------ '- -- --- --------------------- -------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ------- ---- - ----- --- - -- - ------------------------------------- ------------------------------------------------- ----------- --------------- <br /> ------------------------------------------ -------- -------- - -------------------- <br /> ---------------- <br /> -------- ------------- --------- ------------ - - - ---- - - ---- -------- -- ---------------------------------------------------------------------------- -- --- -- ------- <br /> F'^' Ins ection b Date -----G <br /> ---------- <br /> / -� ------ <br /> 5A - 094 IN LOCAL HEALTH DISTRICT <br /> 1-'68 Rev. <br />