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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------ ------- - ------- ------------------------------ <br /> ------_---- (Complete in Triplicate) Permit No. .7.7.r-7�-..... <br /> ---_----------------- --_---.------,.._--..---.-__-. This Permit Expires 1 Year From Date Issued <br /> Date Issued .�]...l.l.._"i. .Y <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 _ _. f..._- }1� .:_ ----------------------------------------CENSUS TRACT --- _.__.__-.__._. <br /> Owner's Name -MA's--'----c��.�._.S /� A - - .... Phone ................................. <br /> ,,,� <br /> Address _���a---/kw� oi -------- --------- --------••-••----••-•••••---•--•_.:::.City �f = = l = _-•--•-----------------•-----_--_-___---- <br /> Contractor's Name --- ---- -------------------- ------------ ---_-----.License # .-.------------ -------- Phone ----------------------_------ <br /> Installation <br /> --•---------•--- --•-._Installation will serve: Residence[9-<partment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other - -- - -------- -------------------- <br /> Number of living units:..,..,------ of bedrooms ..._ . __Garbage Grinder ------------ Lot Size -----•••-•--- <br /> Water Supply: Public Sys 'tem and Warne -__1 ,.------------------------------•-•-•-•------ Private ❑ <br /> I Character of soil to a depth of 3 feet: , Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ---- If yes,type .-..........--------- ---- - 9 <br /> (Plot plan, showing size of. lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> �D <br /> NEW INSTAUATION: (No septic bank or seepage pit permitted if public sewer is available within 200 feet,) �. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-------- ------------ _- -- Liquid Depth -------------------------- <br /> Capacity ................... <br /> ---------__.._.__---._Capacity------=--•--.._.--- Type -••----- ----------- Material-------------------- No. Compartments ------ ............... <br /> Distance -to nearest: Well :-..----_-__--------------------__Foundation _. --- --------------- Prop. Line -_-.--_-.--.-.------- <br /> LEACHING LINE [ ] No. of nei =.--- - -. .--- . Length of each line---------------------------- Total Length ............................ <br /> 'D' Box ---- ,Type Filter Material .-_--._----__--__Depth Filter ,Material ............................................ <br /> Distance to nearest: Well .--_................... Foundation _- ._ ----------------- Property Line ........................ <br /> SEEPAGE PIT [ ] Depth _ _ _ .. ... _. Diameter ---------------- Number ._ ------_---------------- Rock Filled Yes ❑ No I] <br /> WaterTable Depth ------------- ----------------------------------Rock Size ---------- --------------------- <br /> Distance to nearest: Well ........................................Foundation ...............__- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..........-----------__.........._.------ Date ...-_--____.__.__..__-___-____.___) <br /> Septic Tank (Specify Requirements) ----_---___ _ . <br /> Disposal Field (Specify Requirements) - -1---------- ------ -- ------ ------•-----••------ <br /> s'2... ......•-•• -------------------------------------------- -------------------------------•-•------------•--•---------------•--•-•---------------- ------------------ <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, I shall not employ any person In such manner <br /> as to become subject to Workman's Compensation s of California." <br /> Signed ..�l ,lv ...-- _-- _-- ,_,- Owner <br /> By ----- ------•------ --------_---_------------ w------ ---- -------- - ------------------------- Title ---------------- --- -----------------.......... - ----------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....................................................................... ... DATE7!7._Z7,._2.42 ._.. <br /> BUILDING PERMIT ISSUED ------------------------------•-------• ----•------ ----•-------•------------------- --------------•-_.._DATE .----------------------------------------- <br /> ADDITIONALCOMMENTS ..-------•------------•------•--•..................•---.-_-......---•--••---•--.......---------•-•----••-•-- ------•---•-----......._.__...__.-----------_.... <br /> ............................................... ------,-- <br /> ----------•---••------....-- ....................................................... -----------------------------------7.6w-7 Inspection by: ............1. . •----..•-•----•-•-• ----Date ___--�s--�l-� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />