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�- FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> lYlr= <br /> ��yyyy��_. �f <br /> ✓-=7f--. Permit Na. /1 � <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued _e: � <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 /> JOB ADDRESS/LOCATION ---------------------- -------------------------------------CENSUS TRACT ------ -`------- ----------- <br /> Owner's Name -----1'm-----c --------------------------------------------------------- --- ---Phone � 'ry- � -------- <br /> _Qyi_�=;------------------ -- ----- - sem- ------- ----------------------------------------- <br /> Contractor's <br /> -----------------_---------------------- <br /> Address ----------- ---- - -------•--• City ---- -� -' - <br /> Contractor's Name ----- ..__ ------.License # <br /> Installation will serve. Residence tA Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ------------ ------------------------------- <br /> Number of living units:_______ Number of bedrooms -..`------Garbage Grinder fvv---- Lot Size _/_pOH/S' -_--__-______.___ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'[Z Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam "❑ <br /> Hardpan ❑ Adobe ❑ Fill Material _._______-__ If yes,type ____________________________ <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 TANKze-__ ___1�_5___.Y_5_ _ 1----------_ <br /> f 7 Al:� � ----- ----- Liquid Depth ------------------- � <br /> Capacity 0.�°jQ`_ Type/-OP Z Material_ l L� rNa. Compartments __________________ <br /> Distance to nearest: Well -----�0-------------------Foundation _`a_______________ Prop. Line _S __--...:..______ <br /> LEACHING LINE ( No. of Lines ______ <br /> [ �-------------- Length of each line---,g<O.---._------------- Total Length _f-T-4?........... <br /> .-- <br /> 'D' Box es _ Type Filter Material --IfO4'4&---Depth Filter Material -- y_____ ___________________________ > <br /> Distance to nearest: Well _.......... Foundation ---fid-------------- Property Line __S_________----_-- - Q <br /> SEEPAGE PIT [ } Depth ________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------.-- ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- ------ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------- ----------------1---------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------ ----------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> i (Draw existing and required addition on reverse side) <br /> 1 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 su 'ect to/ or man's Compensation laws of California." <br /> Signed ------ ` '---------------------- ------------------------------------ Owner <br /> BY -------------- - -------- -- ---------- ------------- ---------------------- Title ------------------ <br /> ----------------------------------- <br /> (If other than owner( <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ......t-�}�'-�y-K-,k----------------------------------------------------------------- DATE ~f5^ 71 ------------------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE _.----------- ----------------------------- <br /> ADDITIONALCOMMENTS -----------------------------------------------------------------•----------------------------------------- --------------------------------------- ----------- <br /> ------------------ ----------- ------------- ------------------------------------------- ----------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -- -- - - ----- ------- ,� n - f - <br /> "�5 <br /> LU Cv _ _ _ - - ---------------------Date <br /> Final Inspection by: _ -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> I <br />