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i <br /> FOR OFFICE USE: APPLICATION FOR -SANITATION PERMIT <br /> ------- ------- ------ (Complete in Triplicate) Permit No. __72__-_ 3 <br /> ------------ -------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued --------------- <br /> - ------------T -- -------------_------------------ <br /> AO I]. <br /> is hereby made 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 /> :. /�A/`f yyy� L� CENSUS TRACT --. '-A ' .. <br /> JOI{ ADDRESS/LOCATION - ---- --- ------------------- -- ------------ <br /> JO, <br /> Owner's Name - -�7q <br /> ------- <br /> Ad <br /> --- r - �` Phone '� " -` <br /> i. <br /> AdressI . .--J 4 �'Y-------------------------------- - Cit -- - � ------------------------------------------ <br /> n,Contractor's Name ---�-----------------------------------------------------------=------.License❑# -------- --------------- Phone --------------------------_- <br /> Ins <br /> -------------------------. <br /> Insl�allation will serve: Residence Apartment House Commercial Trailer Court i❑ <br /> Motel ❑Other -----------------------------------•-------- " <br /> Number of living units:-------I---- Number of bedrooms __J7...Garbage Grinder _.---------- Lot Size --_ --_---------------------_---- <br /> I�: <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private �] <br /> Clift ratter of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam:H�- - r <br /> Hardpan Adobe '❑ Fill Material ------------ if yes, type ---------------------------- <br /> (PI"ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> I{. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] (,J <br /> PACKAGE TREATMENT j ] SEPTIC TANK'{ ] Size----------------------------- Liquid Depth -----------------•-.,----- `J <br /> Capacity -------------------- Type -------------------- Material---------- --------- No. Compartments ------ -----=---- V <br /> Distance to nearest: Well --_---------_----------------------Foundation ----------------- --- Prop. Line ----.------__:_-._-_-- <br /> LEACHING LINE [ ] No. of Lines ----------------- ------ Length of each line---------------------------- Total Length ----__---.---..-__-_--_-._ [�►�. <br /> 'D' Box ----- ------ Type Filter Material --------------------Depth Filter Material ------------------------------------•------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --------- -------------- <br /> SEEPAGE AIT [ ] Depth -------------------- Diameter ---------------- Number ------------------------ ----- Rock Filled Yes F] No .❑ <br /> Water Table Depth ----------------------------------7-`----------Rock Size "-- --------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------_------- <br /> Rla'AIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> ------------------------ -----Septic Tank {Specify Requirements) ----------------------------------------- - ------------------------------------ ----------------------------- -------------------------- <br /> ---------- <br /> ------------ ---- <br /> Disposal Field (Specify Requirements) --•- �'° - - - = <br /> X11, <br /> -------------------------------------------------------------------------------------------------- -------------`------------------------------------------- ---------------------------------.--- <br /> (Draw existing and required addition on reverse side) <br /> 1 H11 ereby 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 /> 90 <br /> 111certify 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 becMsub'ecl to Work n's Compensation laws of California." <br /> Signed - - ---Gr-- --_ Z ----------------------- -------- <br /> -------._-_ Owner <br /> BY -t - Title - - <br /> . i <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- —--------------------------- --------------------------------- DATE ---- - <br /> BUILDINGPERMIT ISSUED -- ------------------------------------------------------------------------------------------------------DATE -.-----------------:------------------- ---- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------ -----------------------------------------------•--------- ----------------- <br /> i{ ---------I---------------------------------------- <br /> !----------- ----------------------------------------------------------------------------------- -- ------- ------------------------- <br /> ---- --------------------------- - <br /> - <br /> --- ---------------------------------- - -- - - -- -- ---- - --- <br /> ---------------- <br /> ---------------------------------------------------------------- ---- ---- - - -- - <br /> Final Inspection by: ------------------------------------------- ---------------------------.Date -� <br /> .11 <br /> J SAN JOAQUIN LOCAL HEALTH DISTRICT w� <br /> E H. 9 1-'68 Rev. 5M <br />