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IKOR OFFICE USE: <br />' APPLICATION FOR SANITATION PERMIT <br /> a (Complete in Triplicate( Permit No. <br /> This Permit Expires ! Year From Date Issued- bate Issued4_'.�?-. . <br /> Application is hereby made to We 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 Regulatlonst <br /> 333 V <br /> JOB ADDRESS/LOCAT! N ._..... ................... .....i7_...-----................-._.............. ..--CENSUS TRACT __._...._,................ <br /> Owner's Name .. .... _ ._. .._•-- I. . Phone <br /> ..... _-•--------------------------------- <br /> Address ._....City c . <br /> :.3. ..... _......... ...-_._ ...................... <br /> Contractor's Name ---- --- ----- ------- - ".......... License # Phone <br /> .............................. <br /> Installation will serve- Residence Apartment House 0 Commercial❑Trailer Court 0 <br /> II Motel E]Other -----�---_�---•-••-------------- ...... <br /> Number of living units:----- Number e r ___2,. Garbage'Grinder _..`..._:___ I_ot Size ................:..... .:.. ' <br /> j Water Supply: Public System and,name <br /> • •-•-- ..................._ ,._...:-_.. ----------------Private ❑ <br /> Character of.soil to a depth of 3 feet: San 0 Silt❑ Clay "Peat❑ Sandy Loam fl Clay Loam <br /> Hardpan ❑ Adobe: Fill Material ............ If yes,type ............... ............ <br /> r <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: INo septicitank or seeps a pit permitted if public sewer is available within 200 feet,) <br /> TREATMENT• �._ � <br /> REATMENT ( ] SEPTIC TANK Size...•--------------- Liquid Depth ._........................ <br /> Capacity r �D---....- Type ---------_-------- Material P#WO.Vd.No. Compartments ........ <br /> Distance to nearest: Well ------------------------------------Foundation ------,--_--__---___ Prop. Line .-------------- <br /> t <br /> LEACHING LINT: O No, of Lines ..... .__ <br /> '� _ 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 ...J.............. Diameter ................. Number ............................. Rock Filled Yes ❑ No o . <br /> } <br /> Water;Table Deli ---•-------------------- --------•----- ------Rock Size -•-•-•--- ............... <br /> Distance to nearest: Well .................... jN <br /> ---•---••----------------Fovndatian -------------••----- Prop. Line -•-•-------------•---� . <br /> ITION#Prey. Sanitation P it# .... ---------REPAIR/ADDITION ------�:•--•-• - ) <br /> Septic Tank (Specify Requirements) . .-� Q.�.f�' t�. � �{ , ............... <br /> '} <br /> Disposal Field (SpecifyRequire pts ..........................-..:...._....------------------- <br /> ----- - ----------- <br /> ----------------------------------------- --•------------ -------------------------------------------------------------------------------I......................-•...... ------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 ficen- ; <br /> sell agents signature certifies the Following: j <br /> "I certify that in the performance of the work for which this permit is issued, !'shall not employ any person in such manner <br /> as to beco ubjeci War an Comp tion law gIlfornia." <br /> Signe # <br /> Owner i <br /> f <br /> By ....... - -- •----- Title •-------•-- ................... •---------•----------,-...-.....-. j <br /> (if other han ownerl i <br /> PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ - -- ------ - -• .. DATE -/ 'f�"-� I <br /> -------- <br /> r BUILDING PERMIT ISSUED ---•----- ------ --• -• - - ----------------- DATE _... <br /> ADDITIONAL COMMENTS ....... . <br /> ....!......._._...,.. <br /> •--------- ------ -------- ` I <br /> ....................-11 •... --- -- -- -- A.. <br /> ---------i....................................... ......... <br /> 6.................. •.. ¢¢ . . .........•...............................•----........--............................. -•-•.......----------............................. <br /> , <br /> Fina! Inspection by: <br /> ....................,-..................... -------- ----------- ------Date .../G, <br /> f <br /> EH <br /> 13 2h 1-6 AN JOAQUIN LOCAL HEALTH DISTRICT 8/74 M <br /> a <br />