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FOR OFFICE USE. <br /> y APPLICATION FOR SANITATION PERMIT <. . <br /> •---•...... <br /> ........................ Permit Na <br /> iCom lets In Triplicate) <br /> . ..................... <br /> ................................... ..................... <br /> 6 , Date Issued 3� 7 <br /> ................................................•---..... This Permitfxp res Year Fro DatsIssued <br /> ... .. ......... <br /> I.�// <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 i made in compliance with County Ordinance No. 549 and existing Rules and� <br /> Regulations.: <br /> �J B ADDRESS LOCATIOewO, _ .....CENSUS TRACE ................. ......... .... _ ._P . . . . <br /> Owner's Name .. <br /> -�,.. 144r..................... Phone ... <br /> Address .................. --------I " .� r <br /> ------------- city _..._,`. .... . <br /> Contractor's Name - _ __= L€cense 1� _ 3._ Phone : / <br /> - .. <br /> Installation will serve: Residence XApartment uses] Commercial OTrailer Court 0 <br /> Motel Other.. -__��?!�..._.._.. <br /> !dumber of living units:------------ Number of bedrooms.............Garbage Grinder ------------ Lot Size ......�c��..._.............. <br /> Water Supply. Public System and name -^f ...Private <br /> ........ .......---•-------------- <br /> Character of soil too depth of 3 feet: Sand b -Silt o ; Clay,0/ Peat rl Sandy loam Clay Loam 0 <br /> 1; <br /> Hardpan❑ Adobe o Fill Material `` <br /> ...__._..... if yes,type..... .�: ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse aide.) °D E <br /> NEW INSTALLATION: (No septic tank or seepage pit .permitted if public-sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK[ j Size..................:........................... . Liquid Depth .----_-- ......... <br /> Capacity ---- --------------- Tyle ------- ----- Material----------------... N Compartments ...................... <br /> Distance to nearest: Well .........Foundation ...................... Prop. Line <br /> LEACHING LINE j No. of Lines ------------------------- Len h of each line-.........__.._............. Total length ----------- ........... <br /> p <br /> 'D' Box ............ Type Filter Mater 1 ....................Depth filter Mat ial ............................................ <br /> Distance to nearest: Well} ---- --------- Foundation -.---..-._.--_........ . Property line ........................ <br /> ..... <br /> SEEPAGE PIT [ Depth .................... Diameter. .__, .......... Number ...._....._.._ .......... Rock Filled Yes 0 No (3 <br /> Water Table Depth ............... . ........................Rock Size .........._.. ....-•-•------•--- <br /> Distance to nearest: Well ..Foundation ........ Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------------- 7 <br /> -------------------------••-- Date .---..---------___.._ ........---) <br /> Septic Tank (Specify Requirements) ..................... <br /> � ...... ........... ..... .. ...•.4----......-.-_--- ...... •---•-•--- <br /> Disposal Field {Specify Requirements) ------------- ......-•- �..1�1 .... -------- ...... <br /> - .--------•...1� .. .7.....- <br /> - . , <br /> . <br /> `(Dra <br /> �,w existing and required addition on reverse side) <br /> I hereby certify that I have prepared igi3-'application aria that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health;District. Home owner or licen- <br /> sed agents signature certifies the follgwing: <br /> "I certify that in the performance of-tho work for which this permit is issued, 1 shall. not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------------------•- ------ ---------.:------------ ---------- Owner <br /> .�.. <br /> ----... . . • -- ••` Title - - <br /> . . ..........--_-------------- <br /> By <br /> (if r than owner) . <br /> 5 <br /> FOR 130ARTMENT USE ONLY -- <br /> APPLICATION ACCEPTED BY ------- ------ ---- --- DATE ..----.....:...-.- <br /> BUILDINGPERMIT ISSUED --------- --------------------....-......................._......-----...----....._•---.......-----..._-DATE ------- ............................. <br /> NAL COMMENTS MENTS -rt.-- _ ------------ <br /> -------------- ----- <br /> • -- - ---- -. _.-.----------------------------------------------------------- --- --.... _.._.. <br /> ---- - -- - --- <br /> }. <br /> FinalInspection by: .. ---•__----------------------------------------------------------- ----------------Date ....................-..._.-------.......... <br /> ELT 13 2h 1-68 it-_v. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/71t 3M <br />