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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------------I---- -------- -G` Yd <br /> (Complete in Triplicate) Permit No. _.77 <br /> ----------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San 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 /> 1 <br /> JOB ADDRESS/LOCATION � G -- -- -- --------- - -- ----------� -----------------------CENSUS TRACT --`44----------------- <br /> Owner's Name .___,,. - ° <br /> ------.------ - ---- --------------- <br /> -Phone----------------------------- -•----- <br /> Address --- - ------------!77 r ''"'" " -------- --- City --- ----,------------------------------------•--•--••---•------ <br /> Contractor's Name --- --- --- . -- ------- ---- �----- .-.License # __./Vf3f�Phone --------------------.--------. <br /> Installation will serve: Residence , Apartment House-F] Commercial ❑Trailer Court ;❑ <br /> 1 Motel [:] Other -------------------------------------------- <br /> Number of living units:.------[____ Number of bedrooms ___3----Garbage Grinder ------------ Lot Size _ - ---_---..... <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private Rt <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam X Clay Loam ❑ <br /> I Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type _________________________ <br /> (Pl'ot 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 /> �1 <br /> PACKAGE TREATMENT I ] SEPTIC TANKJ <br /> Size- --___/ -_- / <br /> --- ----d'�� -- ------ Liquid Depth ---�------------------ 0 <br /> _l <br /> Capacity tpd Type Material �st No. Compartments � -------_- 6 <br /> / / S ` J <br /> Distance to nea es�tj: Well --------- <br /> _1F40______________-____Foundation ____44----- ------ Prop. Line ---------------------- <br /> LEACHING LINE [ �No,. of Lines ------ Length of each line- 0-�'___._____ Total Length __-_�4.0 - <br /> .'D' Box ___�._ ___ Type Filter Material _____S__k-__-__Depth Filter Material _ _______________________________ <br /> T <br /> Distance to nearest: Well170/e Foundation __ ® _____-. Property Line ____A------------_'__ . <br /> SEEPAGE PIT [ ] Depth _____________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> i <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- s <br /> Distance to nearest: Well ----------------------------------------Foundation -------------- --- Prop. Line ......... ------------ <br /> REPAIR/ADDITION(Prey. SanitationPermit# ------------------- ------------- <br /> rJ - ----------- Date ------•--------------------------- <br /> SepticTank (Specify Requirements) ------------------•-------------------------I-------------------------------- -------------------------------------------------.------ <br /> ,aE <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> t <br /> ----------------------------------- --------------- -------------------------I-------------------------------------------------------------------------------------------------------- ------ <br /> !(Draw existing and required addition on reverse side) <br /> I heieby 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 man's Compensation laws of California." <br /> Signed -------------------- --- -- ---------------- ----- --------_ ------------- Owner r <br /> By --------------= <br /> -! r Title t. �� <br /> --- --- ---- =-------- <br /> (If other than owner) <br /> YOR DEPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------------------------- <br /> DATE _ r rj <br /> BUILDING-PERMIT ISSUED -------------------------------------------------------------------------------------------------- -------DATE -------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------- •---------:----- <br /> - ----- ------ ------ ------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------- ------------------------------------ ---------------------------------------- <br /> --------------- <br /> ---------- -------- -------------- <br /> Final Inspection by: ----- - -------------- ------------ Date _r�"./ ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M T <br />