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FOR,OF.F. E USE: APP%, ,rATION :OR SANITATION PERMIT `e/ <br /> (Complete in Triplicate) <br /> Permit No. ..._.... .... <br /> _. _. ..........................I....... <br /> ..............I......_.... This Permit Expires 1 Year From Dale Issued 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 /> je :ribed. This application ismade <br /> �^lin compliance with County. Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ... 3.-L' 7.____ > �2___.. ..... __. ...._ CENSUS TRACT ...... ._ ...... ..... <br /> qtPr1 <br /> Dler's Name . .o.R.F. ... Mo..N.7........Ca...r.---................. ..... .............. Phone .................................... <br /> 4crJess _..S. :._.... . . . . . .................... ._....................... -------.... City ....._. t... ........ . <br /> ... . . . . -..... <br /> :ontroctor's Name _._.. ... .��_ [..L„L-:Yr' `{ ......._._..............................License # ���....0.l�..... Phone �1...1i/.���F 1.T�--.. <br /> n: illation will serve: Residence Apartment House-F] Commercial ❑Trailer Court ❑ <br /> MotelOther ................. .. ....................................... <br /> Ji iber of living units:- _..-. Number of bedrooms ..-) .....Garbage Grinder ...._._... Lot Size ................�................. <br /> Nor Supply: Public System and name .........................----------._.___....-........... .................................................Private ❑ <br /> :haracter 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.) <br /> JE ' INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) . ,t <br /> 'ALICAGE TREATMENT I ) SEPTIC TANK N Siae.... .�(,...4i....�-r-r.�.F�.................. Liquid Depth .. ...........-...:....)i <br /> o <br /> Capacity[�4r`o.... Type ............ Material__G ..... No. Compartments r.. .................O <br /> _ Distance to nearest: Well ....................................Foundation ...................... Prop. Line ..................--..9Q <br /> EACHING LINE JK] No. of Lines . ......:^............ Length of each line --- ---..-;t.�<'....._... Total Length ...........5 <br /> 'D' Box 'yam?! .. Type Filter Material .../?Tr'1.:....Depth Filter Material .... ------------- .....--.....0 <br /> Distance/to nearest: Well ...........- Foundation ..... .. Property Line ..................D <br /> .EFeAGE PIT Depth .. ......... Diameter _:3...'f-....... Number .._._l9. ............... Rock Filled Yes ,* No.CE <br /> Water Table Depth ... ................................Rock Size ....../.../ .. . ........ A <br /> Distance to nearest: Well /.5..-z......................._..-...Foundation..:i................- Prop. Line s.................... <br /> EI JR/ADDITION(Prev. Sanitation Permit# --------- ......................_.......... Date ..................................I <br /> MpticTank (Specify Requirements) ......................................................................................-..................................................... <br /> nIsposal Field (Specify Requirements) -..............------...------...----...---...._..-----............-.............................-............._.....---. <br /> ... ...._.__.-......_............------......_........_ ...... ......................................................_..._................_......----._.........-...._..---............- <br /> _......___ ........................_..-... ...................................... -------------------------------------------------- .................................................. <br /> ....... <br /> (Draw existing and required addition on reverse side) <br /> h eby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen. <br /> ed -gents signature certifies the following: <br /> 1 i -tify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> s ttlbecome subject to Workman' Compensation laws of California." <br /> gned ........ _. ...... ..... .. ._.. ..----...-. �...-. Owner <br /> / -- --- --------- Title .. _. . ....................... . _....... <br /> If othe than owner) <br /> FOR DEPARTMENT USE ONLY <br /> _ :.a..rr.,:r. <br /> ,PV.JCATION ACCEPTED BY .. e _.... ...... .. ..................................... DATE ..La_-.....Y.._...�............. <br /> UILDING PERMIT ISSUED .................. ........... ..................................... DATE ....... <br /> ,DDITIONAL COMMENTS .............................................................................................................................................................. <br /> ......_.......................... -- .. .... -- -- -- -- ....... ..................... ....... ............._....................... ...................... <br /> �.... ... ................................................ ........................................._........................................ .................................................. <br /> ....... ....... ................. ............. . <br /> . . _........................... . ................ .. .......... . . e <br /> inn) Inspection by: ..........�.._ . - -- - ----.....-..........................................._.......................Date .�.fJ.1.�.�.�. ......,....... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . H. 13 241-'68 Rev- 5M 7/72 3 M <br />