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FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> /� � ----_------—�''d -- 3 L <br /> f Permit No. 73 <br /> (Complete in Triplicate) <br /> ..........I------------ ---------------------------------- <br /> _.__.________________________________--------------- This Permit Expires 1 Year From Date Issued Date Issued f <br /> Application is hereby made to the an Joaquin Local Health District for a per 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/._/__ -Y/ ---C�- - --- - ---- ----- mac- 1-_ "?---------------CENSUS TRACT --------------------------- f <br /> Owner's Name -C—/ - G--T_S`'- "-=-- -° -Phone _ �_ �`',( <br /> Address ---------- -----------------J�_ City ------------------------------------------------------- <br /> ••- ••• l <br /> /u L-G -- - ----------------- --------License #��-` ----------- Phone -------------------------­ <br /> Installation <br /> '� __ G v i <br /> Contractor's Name -- ----=- ---- ---------` " <br /> ' .-P�----------- ---- S ------._ ...---- � <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> .Motel ❑ Other ------------------------------------------- <br /> Number <br /> -------------------------------- ---- e <br /> Number of living units:-./-------- Number of bedrooms ___________Garbage Grinder ------------ Lot Size ____________________________________________ <br /> Water Supply: Public System and name ---------------------------------------------------------0-------------------------�--•-------y-------Priivate 1­1Character of soil to a depth of 3 feet: Sa ❑ E] ❑nd' Silt Clay Peat Sand Loam Cla Loam <br /> Hardpan ❑ Adobe SA Fill Material if yes, type _________.________________ <br /> t <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 pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK'M F--)0'5 71- ize------------------------------------------------ Liquid Depth --------------------------- � <br /> QV <br /> Capacity - -------------- _ Type ___________ ______ Material____ ______ No. Compartments ------------ V <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line _____________________. <br /> LEACHING LINE �[ ]f/ No. of Lines _________ _____________ Length of each line---------------------------- Total Length ---------------------------- <br /> q_ d / 'D' Box ------------ 'type Filter Material ____________________Depth Filter Material ------------------------.__.._.......... <br /> .._. <br /> Distance to nearest: Well ------------------------ Foundation ------------------------- Property Line �j <br /> --------------------•--- <br /> SEEPAGE PIT [ ] Depth ------------ Diameter ________________ Number -------------------------.__ Rock Filled Yes ❑ No j]O <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation --------------------- Prop. Line ______:_-___:___-.-__ i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -------.---------------_----- --? �y 4 <br /> Septic Tank (Specify Requirements) ________________ K_____oC U <br /> ------------------- <br /> Disposal Field (Specify Requirements) `� -- /� " _, •/�f ..- <br /> --------------------------------------------------- <br /> - --------------------------------------------------- - <br /> -I------------------------ <br /> --------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) G <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 Regulations 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." <br /> Signed ------------------------ ----------------------------------------------------- ----------------. Owner <br /> BY ------ ---------------- ----------------------------- ----------------------------------- T - <br /> Title ---- ----------- <br /> - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _____ __ :. DATE - _`._ <br /> ---------- ------ <br /> BUILDING PERMIT ISSUED -- ---------------------------------------------------DATE -------------------------------------- <br /> ADDITIONALCOMMENTS - ---.------------------------------------------------------------------------------------------------------------------------------ --------------------------- <br /> ------------------- -------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- = ' <br /> --------------------------------- <br /> ------ <br /> ---------- --------------------------------- ------- - - -- <br /> - - -- - -=--------------- <br /> Final Inspection by. --•------------ ------ .Date `� `� <br /> N JOAQ IN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> a <br />