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FOR OFFICE USE: r <br /> �✓�S %a "` s`' APPLICATION FOR SANITATION PE' 'T (��_/bOS <br /> ----. J. A-------- ----- �" Permit No. <br /> (Complete in Triplicate) <br /> - ------------------------------ ---- --------- 3 &9 <br /> -------------------------------------- __-__.._.__. This PermiTExpires 1 Year From Date Issued <br /> Date Issued __....'_.._'_..... <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/-�- I-S. -------�-' -- -_----.-- ---------------------------CENSUS TR��AC//T` ------- --.--------- <br /> Owner's Name ------------ --4f-`- -- ---- - - -------------- --------------- ----- ---- -Phone -.,!_.0 ----- <br /> L /�] <br /> Address -------------------- <br /> City --'� ................ ---......... ...... <br /> Contractor's Name r - ---- - - -oxo--------------License #1107.571------ Phone YKA6:7 .-�p.4_7 <br /> Installation will serve: Residence (,Apartment House❑ Commercial [-]Trailer Court [] <br /> 1 , Motel ❑Other---`--- ----------- ---- ......--- <br /> Number of liortg units:_____ Number of bedrooms,. Garbage Grinder --------- -- Lot Size ----- ----------- ...... <br /> LWater Supply: PyblicySystem and name - - -----------=- _- Yi------_ - ------------_-----------------------------Private <br /> Chars ler of soil To a gEpth of 3.fleet: Sdnd❑ Silt❑1 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> H�`dpan ❑ A013i"N Fill Material .--_____ If yes,type __._.__.___._.__._... <br /> N b�T plan, showing size of lot, location of- system in-{elatwn to wells, buildings, etc. must be placed on reverse side.) <br /> NJEW II STALLATION: (No septic tank or seepage pit-perrmittecl if public sewer is available within 200 feet,) L <br /> PAC GE TREATMENT [ ] SEPTIC TANK[ ] Size_ .._ ------------------------------------ Liquid Depth . ---- -- ---------------- <br /> Capacity -------------------- Type -------------------- Maten -__ 4---------------- No. Compartments .................... <br /> Distance To nearest: Well -------- -------------------Adp. Line .-------- ............ 1 <br /> LEACH NG LINE [ ] No. of Lines __ -------------- Length of each line------------------ �._ . Total, !Pull) .----------- <br /> -----------_-- <br /> L <br /> L 'D' Box ------------ Type Filter Material -----------------...Depth Filter -Material ..__._--_..__..._-___..____ .__ <br /> Distance to nearest: Well ___.._.__.___..... Fou , ti _ _ _ ----- <br /> on -------------- ------- <br /> SEEPA \'r^ <br /> E [ ] Depth ..._. ._._-_.. _.. Diameter ..__._ .___ _ NumZ -... -.__ .-. - . -. Rock Filled Yes ❑ No C1� P -------------------------- _ _ <br /> Water Table Depth ---_------- . __---.--._---_..._..-------Rock Size -----I-------------------------- <br /> I[_ Distance to nearest: Well ---- _'.__.------------...............Foundation .i-------------.---- Prop. Line _.._. ................ <br /> REPAI ADWTION(Prev. Sanitation Permit# _._____._.__.......__................... Date ____..___.._._.___.. --_.......) <br /> Sep pc Tank (Specify Requirements) ------------------------ -- - ------------/-j( Win'' '' <br /> Disposal Field (Specify Requirements) --------- ....-._.. ._�. "1��4 _- -� .._�.._. ..-_.._-..... <br /> ---------- ------------- ------------- - ---- ------------------(---l3- X <br /> --- <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 /> L "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 laws of California." <br /> Signed - __f Owner <br /> C <br /> By - - � �r�4�443 >- t�..�. � Title r <br /> pf of er th wner) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> r APPLICATION ACCEPTED BY ...... .... ... _. DATE _-_L. : . _ ._- <br /> BUILDING PERMIT ISSUED ---------------------------------------- ------------------------- <br /> --------------------------------- .._DATE ------------------ ----------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------- --------- ------------- <br /> ------------------------------------------------------------------------ 1----------------------------------------------------- _- --------------------------------------- --------- <br /> y -------------- -- <br /> ------------------------------------------------------------------------------------------------ <br /> - - - "- ----- - p _ -r?----- <br /> Final Inspection by: - - - ------------ ------- ------- ----------------- -------Date -- - - - --- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT III <br /> E. H. 9 1-'68 Rev. 5M <br />