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FOR OFFICE -';SE: <br /> �F APPLICATION FOR SANITATION PERMIT <br /> ---------------- !Complete in Triplicate) Permit No. -----7=3- --- <br /> S <br /> � <br /> = ---------- - - - -------------------- <br /> --------------- This Permit Expires 1 Year From Date Issued Date Issued ---I I:23 <br /> Application is hereby made to the San Joaquin Local Health District fora 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 ". "; L `vTGc ---------------------- ---- ---- -------------CENSUS TRACT ----------------- -------- <br /> Owner's Name ---- ------"�'--�--��-1--�=�------------- ----------=-------------------Phone ------------------------------------ <br /> ----------- <br /> ----- - -----------------••----- <br /> Address ---------------- -.-/L ! CitY �------------------------------------------------------------ <br /> Contractor's Name - - __!°_-_.____ :/` v_ _ ,� � <br /> --------------License #�.15_ -------- Phone ------------------------- <br /> Installation will serve: Residence partment House-[] Commercial []Trailer Court iQ <br /> Motel ❑ Other -------------------------------------------- <br /> Number <br /> ------------ ----------------------------Number of living units:------f Number of rooms ________Garbage Grinder��`�_ Lot Size � ._-_ <br /> Water Supply: Public System and name --------------- -- ---- — - _--------------------------------------------------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Iit Q Clay at F] Sandy Loam Q Clay Loam [DHardpan EJAdobe Fill Material _e5Z 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 /> NEW INSTALLATION: (No septic tank or seepage it permitted if public sewer is available within 200 feet,)/ r <br /> PACKAGE TREATMENT [ ] SEP�IC TANK: -ze______ __-__.-____--,E---- Liquid Depth ___t � --._-- -___ V <br /> Ca acit �__ <br /> p Y vG Type Mhi- <br /> ate�ig -- ------ Nb. Compartments �----..---- <br /> Di ante to nearest: Well ------------------` �-_--_.__--_Foundation ---- �_�w----- <br /> Prop. Line r_ -_____________ <br /> LEACHING LINE [ No. of Lines -_-____�__________ Length of'�. ach line..__ _I�--------- Total Len th _� __________________ <br /> //�`/ <br /> D' Box.-- ,_ Type Filter Material ___--_ Depth Filter Material -------------------------------------- <br /> __ ____________________--- <br /> U <br /> __ <br /> [Sistance � nearest: Well _��1�-____�_.- Foundation.'/.��-_-- Property Line __-_____�. <br /> .._..----•--- <br /> SEEPAGE PIT [j,�Depth 'J. - _�_____ Diameter - '-__ Number ___ ___`fi--------------- Rock Filled Yes [ -/�lo i❑ <br /> Water Table Depth _-_�I__Q---_J��_------------_--------Roc€ Size __/_ G – ----------- <br /> Foundation <br /> _----._-.- <br /> Distance t6 nearest: Well -------1�------------------Foundation ��__--__-___ Prop. Line �_ _________.. <br /> / Sanitation ---------------------------------------------, -- jDate --- ------------------ -----------) <br /> REPAIF: ADDITION(Prey. Sanitation Permit# <br /> Septic Tank {Specify Requirements) -------------`----------------------' ------------------ -r-_w-. ,...__..-------------------•--•---------------------------• -- <br /> Disposal Field (Specify Requirements) --,-------------- ----------------------------------------------•--------------- <br /> IIt -- ------------------------------------ -----------1------------ <br /> ----------------------------------------------------- -------------------------------------------------------- ---- F ---- -- ------------------------------------------------------------ <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 Rejulations 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." f <br /> Signed <br /> BY ------------------------------- -- ----- v '-------------------------- Ji e - ------------------- <br /> 71 <br /> (If oth r t owner). <br /> FOR DEPARTMENT USE ONLY ` <br /> APPLICATION ACCEPTED BY ---------------------------•---------------------------------------------- DATE ---- is ---------------- <br /> BUILDING PERMIT ISSUED ---- `--------------------------------------------- ---- --------DATE --------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------=-------------------------------------------------- --------------------------- <br /> -------------------------------------------------------------------------------------------------- --------------------------=------------------------------------------------------------------•------ <br /> �� - <br /> Inspection by: -- '\1"" 4'--.---------------------------------------------------- F Date ------- <br /> Final 9- J <br /> -SAN JOAQUIN LOCAL HEALTH (,DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />