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-FOR OFFICE USE= <br /> APPLICATION! FOR SANITATION PERMIT <br /> ........................................................N 1;.- (Complete in Triplicate) Permit No. .. ... <br /> .................................a..._. . �� µ This Permit Expires t Year from Date issued Date issued .,P `. ...... <br /> ........ <br /> i <br /> Application is hereby rnade�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 /> .LOB ADDRESSAOCATIOry�. ...�,F'Z z... .,,. .c. .. . �//1.� �........ CENSUS TRACT .......................... <br /> } Owner's Name ...... �Ih .�c/i4 r: . .... .............. Phone ............ ....................... <br /> Address .....- ` .------ .•.••-•. - .�.. . ..� ----.............City G ! ..................................... <br /> Contractor's Name ...i. � , -. # - '�...c� •-,?..License #12,6.7111 . Phone .. . :' .�f. .. <br /> Installation will serve: Residence OrApartment House C) Commercial❑Trailer Court ❑ <br /> Motel ❑Other............................................ <br /> Number of living units....../ <br /> ....... Number of room ._.,r .-..,.Garbage ander .... ._... <br /> , "Lot size .. .. ld...-- <br /> Water Supply: Public System and name - !11:: :....._f�.. .-. _.................................. ...............Private❑ <br /> Character of soil to a depth oaf 3 feet: Sand❑ Silt❑ _ Clay ❑ Peat❑ Sandy Loam ❑ day Loam ❑ <br /> Hardpan© i Adobe fW Fill Material ............If yes,type............... ............ <br /> ,(Plot plan, showing size o. Lot, location of iyste . in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLAtIONe (No septic tank or seepage pIt petmitt If public sewer is available within 204 feet,( <br /> fS; C'Sl -1 <br /> PACKAGE TREATMENT ( ] SEPTIC TANK( ), SI a.......,... .. Liquid Depth ...................... <br /> Capacity •............... Type .................... Material..................... No. Compartments ...................... <br /> I Distance to-nearest: Well'. ... -...............................Foundation ..................... Prop. liner.......`........ <br /> LEACHING LINE i No of Lines ........ ............ Length of A4 _..6.7 Ins... ..6.7 f .......:. Total Length ..?`.�._............. <br /> 'D' Box ..` '. Type Filter Material .� ....-Depth Filter Material .,l ..................... <br /> lcJU !. ......... ................... <br /> Distance to nearest: Well : .......... ... Foundation .,��.... _. Property Line <br /> s. SEEPAGE PIT Depth .! .�..... Diameter k���.. Number ----.�................... Rock Filled Yep No C7 <br /> Wafer Table Depth .... . ...... .. ... .:Rode Size .. <br /> Distance to nearest: Well _ fi ......tFovndatlon . . ..�.... Prop. Line . .............. <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............. .. Date ......:.........................} M <br /> Septic Tank (Specify Requirernents) ..................... .. -- .+ ••------•-- . <br /> •. ...... ...... ... ................. <br /> Disposal Field (Specify Requirements)' _... ,,L ..._ .. -:`14�` �............:.... <br /> .......................................... �. .................. 772-CA- .. . ................. ...........................__............................... <br /> ................................................JI <br /> ................ ..._.._..i_... .......... .......................... ........ ..___.............................. •................. <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 kaws, and Mules and Regulations of the San Joaquin Local Health District. Hone owner or lleeet- <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 rnattne: <br /> as to become subject to Wgrkman's Compensation laws of California." <br /> Signed ........�......................... ........... ......................... Owner <br /> . By ........... .. . Jitle ......44, .-.-..-..._.....-.................---......... .......... <br /> 7 <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 8Y r- ................................................................ DATE .c ........................ <br /> BUILDINGPERMIT ISSUED0....--...............................................................---........................ ----•-.DATE ............... ............................ <br /> ADDITIONAL COMMENTS !i ;....................................................... <br /> . <br /> ..........................................!.....................................-................................................................ :...:........-..............-......... <br /> ........................................ .!E.... ..............................................................................................:...................................................... <br /> f......�....... --•--•------------------- .-....... . .. ...........-.-.....-......--. . ..--- ...................... <br /> Final inspection by: 6 ................................................... Oats ..... <br /> ., EH 13 24 1--613 ROV.11 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 5/74 3H <br />