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FOR OFFICE USE: "PLICATION FOR SANITATION PERF" <br /> �.. Permit No. -- V.-X0.2 � <br /> , (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued .... 71 <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 rr1 I' nc w t Cou t Or a e 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -C. -- �.,/ W.1' 9 �`[ Y'`-`-----�-- ----------------".'�.-CENSUS TRACT s .................... <br /> Owner's Name -- -----•----- - ---- ---:.._ Phone --------------•--••------------•--- <br /> Address -------------O. _ y City -- <br /> Contractor's Name - ..License # .�. p 3 Phone <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ------------------------------------ ------- <br /> Number of living units:............ Number of bedrooms ...._.----..Garbage Grinder ------------ Lot Size --------.------------....................... <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 /> 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.) c <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) o <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ J Size------------------------------------------------- Liquid Depth _---_-_.-----_--------- <br /> Capacity ------------------- Type -------------------- Material.----_------------- No. Compartments ...................... F <br /> Distance to nearest: Well --------- --------------------------Foundation .__.....__...__----_- Prop. Line ._..-------------.---. � <br /> LEACHING LINE [ J No. of Lines ------------------------ Length of each line........----_-_---- ------ Total Length ............................ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ............................................ <br /> Q <br /> Distance to nearest: Well ------------------------ Foundation ------__.----_-_--.--- Property Line .._...---------.-..----- � <br /> SEEPAGE PIT [� Depth -----o -` .�____ Diameter -.41 ----- Number __._...6...... .......... Rock Filled Yes L� No C] t <br /> / , <br /> Water Table Depth L?© ------..Rock Size I <br /> Distance to nearest: Well ........... ..SOS -+......----.Foundation ----- P......_.. Prop. Line -------_------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ......------..---------------..-.-) <br /> Septic Tank (Specify Requirements) ---------------------------•------••------• -----•---------••-- --------•- ------- ------------------•----- •--------------- <br /> DisposalField (Specify Requirements) ------••------••------•-------•-------------------- --------_----------------- ----------------------------------- ---------------- <br /> ---------------------------------------------------------------------------------------------------------------_--- --------------- ------------------------------ ---------- ------------------ <br /> h <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 laws of California." <br /> Signed --- ----------------------------- -- - Owner <br /> ` f(w ¢t� Title (fery " ----------------------------------•---- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY! .. ---------------------------------..._...•-----------------------------. DATE - - .` . V....--•-------- <br /> BUILDINGPERMIT ISSUED ---- --------- -----------------------------•--••-----------•----•-----•--•------------------------------.DATE ----•---------•----------------•----..----- <br /> ADDITIONALCOMMENTS ----- -------------------------••--•----------•--•-----------•--------•-••---------------•---------------•-------•---------------- •---------••--------------- <br /> -----------------------------------------------------------------------------------------------------•-•-------------------------•-------•------------•- <br /> ----•-----------------------------------------------•-------•------------------------••----------------•----•----•--•---•-•-------•-•------------- <br /> ---- - -------•-•-------------------------------------•----•-•----------------- <br /> Final Inspection by: -------Dat .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />