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FOR OFFICE APPLICATION FOR SANITATION PERMIT <br /> f <br /> . '0 4f I - --- Permit No. <br /> -- - ------- ---- ----4 <br /> *- (Complete in Triplicate) <br /> -� Date Issued.- <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 compliance with County Ordinance No. 549 and exiting Rules and Regulations: <br /> �#3 I N_; E,-l7V ra- --CENSUS TRACT - -- __ - <br /> "JOB ADDRESS/LO TION <br /> + ' -- ---- Phone----------------------------- <br /> _& <br /> --''------------- ------- <br /> �._ _ 9 1 <br /> Owner s Name'..:._ <br /> 11 City - --- LC9�t> <br /> Address -+tl- �t `------------------------- / <br /> Contractor's Name ------.- ------ ---------------------:--------- ---------License # a`J -- Phone <br /> Installation will serve: Residence artment House❑ Commercial:❑Trailer Court i❑ `A <br /> .' <br /> A.5 • <br /> Motel ❑Other ---------------- -------------------------- �~ <br /> Number of edrooms __ -_-_Garbage Grinder.-_ Lot Size ` <br /> Number of living units:__._ __ +.. <br /> Water Supply: Public System and name -- __-- -1�,,h�.Ec.ra;t�_ -- --.--`-'� ._'` Private ❑ <br /> Character of soil to a depth of 3'feet: Sdnd'❑ Silt❑ &y E] Peat E] Sandy Loam ] Clay Loam El <br /> type ------- ---------es, <br /> Hardpan ❑ Adobe Fill Material ------------ If Y t . W <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,) 1 <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ , Size.---- -- -`-- ----------------- Liquid Depth ?r---•.----- <br /> p -------------•-------- <br /> Material- fa. Com artments <br /> Capacity �.�,_flT1 ,, --•-- Type ��'-�-'-- - �`�- --- <br /> f1- , .._..,........*...,.....,�_,s �. <br /> to - ---------------------• O-'/--••--•---- <br /> r <br /> LEACHING:UNE [ . No. of Lines _.- ------------- Length of yea{h...line--- .- Total Ler�g#h <br /> 'D' Box , p_&-- Type Filter Material _ I =- '�Depthy Filter Material _ _ <br /> ► I ` ------------ Property Line __fir_-----.-- <br /> Distance to nearest: Well -------_- _%___-_----_ Foundation ___ ___._ _ <br /> I ``;' __--_ Rock Filled Yes No <br /> SEEPAGE PITT [,�] Depth - -- --_---- Diameter - _----- Numf�erw.-: -- - + r r <br /> & ri � i . , <br /> Water Tablel.Depth __ �1------------------------------Rock Size -- <br /> �..� / <br /> t' Distance to nearest: Wel! -----------------------------------=----Foundation ---- --p l -_-- Prop. Line <br /> REPAIRJADDITION(Prev. Sanitation Permit# --------------------- ---- Date -----------_----------------------) <br /> Septic Tank (Specify Requirements) -- ----------------------------------------- ------------------------------------------------- ------------------------------------------ <br /> Disposal Field (Specify Requirements) -- --------�- -------------- ------------------------------------- <br /> -_ » .N .__ <br /> ---------------------------------------- <br /> ----------------------------------- <br /> ----------------------------------' -----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, and Rules and Regulations of the San 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, 1,shall not employ any person in sbch manner <br /> as to become subject to Workman's Compensation"Itiws-of California.' ) <br /> Signed --------- ------------ Owner <br /> Title -- ? <br /> (If er an owner) <br /> r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -Lo' - --. -- DATE -- --��------r-------•----------- <br /> ____ <br /> BUILDING PERMIT ISSUED ---- - -- ---------- ------------- -------------- ----------- DATE ---------- • <br /> :- --------------------- <br /> ----- <br /> ' ADDITIONAL COMMENTS __ '----------- • <br /> �� --------------------- <br /> ---------------- ---------------------------- <br /> -------------------------------------------------------------------- <br /> ------------------------ - -----------------------'-- ----- ------------------------------------ --------------- --------------- <br /> __ ---- ------- <br /> ------------- --- <br /> - Date �� - U <br /> - - T.H_DdSTRIGT <br /> Final Inspection by: ��_ --- - a 4J <br /> _ SAN.JOAQUIN- LOCAL HEAL. <br /> E. H. 9 1-'684ev. 5Mh� <br />