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FOR OFFICE USE: <br /> �� ® APPUCATIbN FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> ---- --- ----------------------------------- ----------- <br /> - Date Issued _9-_6�r_64 <br /> ------------------------__---------_-----_--------_---- This kermit Expires 1 Year'From 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 ounty Ordinance No. 549 and existing Rules and Regulations: <br /> ]' 1 _7D ---------- -- --CENSUS TRACT -------------- <br /> JOB ADDRESS/LOCATION .-- / G� `` <br /> Owner's Name ---------------- - ------Phone b`M-_I--------- <br /> r� ,/ <br /> Address --------------------=---rl Q r c �� ' V" �-. City <br /> Contractor's Namep ¢.---------------------------License # 5�1 Phone <br /> Installation will serve: Residence A artment House-House-[] Commercial : Trailer Court i❑ ' <br /> Motel ❑Other -------------------------------------------- /�,� <br /> Number of living units:-----1-_-___ Number of bedrooms _-__45 - e Grinder ------------ Lot Size -----ac-__ L/--_-___--_ <br /> 4 � r <br /> Water Supply: Public System and name ---------------------------------------------------------------------- ------------------------------ --------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ;Q Clay Loam <br /> Hardpan ❑ Adobe❑ Fill Material ------------ If yes,type ---------------------------- j <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 seep ge,.pit permitited if public sewer is available within 200 feet,) t <br /> PACKAGE TREATMENT [ ] SEPTICTANK'� ] 5iie-:'°'--�- ---------------------.-- -_-_ Liquid Depth ---_._--_i.----__---- <br /> { t <br /> Capacity -------------------- Type -----------•-------- Material ------- No. Compartments ------- •// l y a <br /> Distance to nearest Well ------------------------------------Foundation --.---_--------------I_ Prop. Line ----. ..__ <br /> LEACHING LINE [ ] No, of Lines ------------------------ Length of each line__k--- -- -__+------------ Total Length ----_----�------_--_-�_-_= O .. <br /> 'D' Box "_-_-- ---- Type Filter Material --------------------D.epth. Filter Materia! _-___------_--'_..__.__._______,_.__.__._ <br /> -r ., .,I <br /> Distance to nearest: Well""__f_______________ _ Foundation __ _------.-___,--__ Property line - <br /> SEEPAGE PIT [ J Depth ------ Diameter ------------ .-- Number ----------------------------- Rock, Filled Yes ❑ No ❑ <br /> Water Tab#e Depth ----------------•--------------# ----------Rock SizeE - --V-------�--- ---y <br /> Distance to nearest: Well ------------------------ -____-.-__---•_Foundation --------------- ---- Prop. Line J <br /> -_-_--_-- <br /> t 3 1 'rt <br /> REPAIR/ADDITION(Prev. Sanitation Permit,# -------- -------------------------------- <br /> Septic <br /> _______.__________.___.________ ) <br /> Septic Tank (Specify Requirements) ------------------------------'=--------- -------- -``•w-,1------ -------------- •------------------------- <br /> Disposal <br /> ------------------ - <br /> Dis osal Field (Sptecify Requirements) -------- - ' - ------------------------ ------ --- <br /> --------------------------------------------------------'----- f � . --------- ,- -------- ---------------- <br /> ----------------------------------------------------------------------- -------------------------=-----------------------------------=--- -----------------------------• <br /> .(Draw-existing and required additiononr'r"everse side)-' " = a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin i <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: k <br /> "I ceitifyAthdt=in the performance of the worklor which this permit is issued, I shall not employ any person in such manner <br /> ,a. r <br /> as toFbecome subject to Workman'sItompensation laws of California." <br /> 1 <br /> Signed -------------------------- �P ------------------------ Owner <br /> BY - ------- <br /> --- Title ----- r f <br /> (If oth tan owner) <br /> i FOR DEPA1tTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY ------ s-- c- -------------------- ----•----------- ' <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------------ ------------------m <br /> -- ----DATE ----------------------------------------- ' <br /> ADDITIONAL COMMENTS ------------------ ,-% ---_ - ' <br /> ------------------- ------------------------------------ -------------------------------------- <br /> ------------------------------------------------------------------------- - -------- ---------------- v i <br /> ' - <br /> ---- - ----- <br /> Final Inspection by: Date = ___5tfr-_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 68 Rev. 5M i <br />