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A, FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT r <br /> ------------ <br /> �cY b �;3- -� � -- ---- _ <br /> ----_r_.._ <br /> -- {Complete in Triplicate) Permit No. <br /> r------------- <br /> Date Issued <br /> -------------------_--------------_ This Permit Expires t 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 County/Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . CENSUS TRACT <br /> ,--vf� r `;o------Ima = ----------- ----= _ _ <br /> Owner's Name ------ -- - ----��--------------------Phone ---------------------------------•-- <br /> Address �= '---------------------•--. City ----fir or,&� --------------------------------------•-- <br /> i1 � <br /> Con#ractor's Name ..� F-------------- License #� 2 �' Phone �' _ `� � <br /> Installation will serve: Residence [ Apartment House,❑ Commercial []Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:----- Number of bedrooms --_--__Garbage Grinder _/VC1._-_ Lot Size -- -�r�.grx1`.____._._____._. <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 loft, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) VV <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC.14:— Size__ ------------ Liquid Depth _.14-------.__________.. <br /> Capacity ______ Type / T Material Y "j No. Compartments ;Z---------------- <br /> Distance to nearest: Well ____ _C?_ __________________Foundation _/d---------------- Prop. Line ---_J_7_'_____-_..._ <br /> LEACHING LINE [.4—No. of Lines __.__ - <br /> -------------- Length of each line-----qfJ---------------- Total Length __1�1--_-----•---------- <br /> 'D' Box _ __ Type Filter Material -h-19-6k____Depth Filter Material --/£%--"_------_------------------ <br /> ---------- <br /> _________•-_._ _ ._. <br /> r ! i <br /> Distance to nearest: Well --�------.____-__ Foundation_ __Y_9---- Property Line - ___...._._._._.... <br /> i w�f 5 e 'e, <br /> 3 <br /> Depth 67 _._ �r� Number _-__----._- --___ Rock Filled Yes-R] No 0 <br /> SEEPAGES [� p --- -- --------- Diameter .-- -- ---___-- <br /> Water Table Depth ------ - ------------------------ --------Rock Size _-1I —All ll----------- <br /> 4 D - ---_Foundation lO-`____.___ Prop.)Line - `... <br /> Distance to nearest: Well ------j___________ __________ --`----_._. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---------------------------------------------------_ Date -----------------------•----------) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- <br /> DisposalField (Specify Requirements) ------------------------------ --------------------- ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------- ------- ------ --------------------------------------------------------------- <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. Horne 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 Workm Vs Compensation laws of California." <br /> Signed ---7wW k <br /> -------------- Owner <br /> BY --------------------------- ------------------- Title ---- ------ ------------------ ----- --------------------- <br /> (if other than owner) <br /> FOR .DEP ENT USE ONLY f <br /> APPLICATION ACCEPTED B1-S-- --- ------------------------ DATE <br /> BUILDING PERMIT ISSUED --- --- ----------------- ---------------------------------------------------- ------------------------DATE ------------------------------------=------ <br /> ADDITIONAL CO TS ---------------------------------- ---------------------------------------------------------------------------------- ------------ ------------- ------ '---- <br /> - <br /> ---------------------- ------------- <br /> E <br /> ---- e-------------- ---------------------------------------------------- <br /> ------------- -W• <br /> - ---- ----------------------------- ---------------------------------------- = ' <br /> Final Inspection ---------------------------------------Date -------± <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />