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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> g V <br /> V (Complete in Triplicate} Permit No. .-Z-r:��/�: <br /> ... -b--•....----------------------------------.--......, s �., <br /> ............................. .........I............ This Permit Expires 1 Year From Date Issued Date Issued ............ <br /> k <br /> Application is hereby made to the Son 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/LOCATI N .. ........ <br /> `13.-= .. .. ............... ...... �'...,..._.e......CENSUS TRACT <br /> Il Owner's Nome .-.....- !..... ......... =._77 . . .�_ 7"­_- <br /> :� x'.'.Phone .................................... <br /> Address <br /> .-± ..... ............. City <br /> Contractor's Nome . ILicense # JBJJ__;��- Phone .............................. <br /> Installation will serve: Residence []Apartment House❑ Commercial .❑Trailer Court 0 <br /> Motel ❑Other ...._'>7^wrr4..... . <br /> Number of living units:-.-.J...... Number of bedrooms __- -........Garbage'Grinder ...... Lot Size .....elc-_7.!. ............. <br /> Water Supply: Public System and name ................--------- .......... ..--------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom <br /> Hardpan ❑ Adobe ❑ Fill M6terial ....---__ 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 /> t <br /> NEW'[NSTALLATION: (No septic tank or seepage pit permitted if public sewer is ovollablia within 200 feet,) y <br /> t1 S <br /> PACKAGE TREATMENT [ SEPTIC TANK Siae..a�r� .•--•_--X..----.. .............. Liquid Depth ...�...._...._......._.. <br /> No. Compartments ..��................ <br /> Capacity l. Q.. Type. -_----- --..- Mdteriala�......� / i <br /> Distance to near st: Well .........�o./r--------------Foundation -----�.�------•--•. Prop. Line .0.................r <br /> LEACHING LINE No. of Lines ......... ...... <br /> [ �--------- Length of each line......../AQ.....:....... Total Length ............. <br /> D' Box ..en..... Type' Filter Material ...:_:�.!Q...._.Depth Filter Material Jf_1 <br /> � / <br /> ................................. <br /> Distance to nearest: Well ..:..._ '..�..P.._.._:._...FOundation ........ Property Line ....r.... <br /> _�LT [ I Depth ��.,*Number ............... Rock Filled Yes <br /> - J y .. <br /> Water Table Depth --- ...... - ......................Rock Size ..-_.....-�..__�`._�..r...--- � <br /> Distance t.o nearest: Well ............d9.P......................Foundation ....d?.......... Prop. Line ............... j <br /> REPAIR/ADDITION(Prey. Sanitation Permit# --..-...----.-•----------------•-------.__-- Date ................................ <br /> .:} <br /> Septic Tank (Specify Requirementsl -----------•----••---------------------------•--------•-----•...--•-•_... <br /> Disposal Field (Specify Requirements# ......................................... ---------------------•----------------------------------.-------.-..----- I <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, an{d Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify shat 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 subject to Workman's Compensation laws of California." <br /> Signed ---------------------------------------- ......... .. . - -------- Owner <br /> By _........................... sef ` r . ........... Title .. . ................ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION .ACCEPTED BY DATE �-� <br /> • ............. ..... <br /> BUILDING PERMIT ISSUED ................:....... ..............DATE --•--. .................................... <br /> ADDITIONALCOMMENTS -•---•-----•--{.........................................-------------.......... ....--.........---•--................----••---.... ......... ................. <br /> :. <br /> .................................................-.......................................... <br /> ...-.....................:..............•............ ---........--......-..........-•----.:..._........_....._...._....._._.... ..... ._..... .......... <br /> . ........................................................................................ �j+ r <br /> Final Inspection by. Date <br /> : ....... ... ........ II <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E_ H_13 24 1_'AA Rpv_ SM 7/72 3 X <br />