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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No. _ 5� <br /> . _ <br /> ----------------- -------------------------------------- <br /> (Complete in Triplicate) <br /> Date Issued <br /> - <br /> -------------------------------------------------------- This Permit Expires 1 Year From Date Issued <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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION '__----_-C•Tl------.__4-,-7 .,2 *,-/✓ - __-_--CENSUS TRACT ---------_............... <br /> Owner's Name Ss <br /> e-------- <br /> (y- / . - <br /> Phone---- ----------- ---_ <br /> ---------------------------- <br /> Address ----- 1 - -- u-6s�--------- l ----------------------------------------------------------------------- city - <br /> Contractor's Name ----'�---h ��v!k�------- --------------------License # -----—----------------- PhoneS <br /> --- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court l❑ K► <br /> Motel ❑Other -------------------------------------------- A. <br /> Number of living units:--- ----- Number of bedrooms ---I------Garbage Grinder IYa------ Lot Size __ -XlLq ` a----__- <br /> Water Supply: Public System and name "-----p�$ ------------------------------•_Private E] <br /> Character of soil to a depth of 3 feet: Sand'❑ 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 TANK[ ] Size--____10200- -CAA Y ","o Liquid Depth -----Y------.......... <br /> Capacity 1-2-904-4Z--- Type -_yI'=-_CA5 TMaterial____ _ -______ No. Compartments -------------- <br /> n <br /> Distance to nearest: Well ----------�------------------Foundation -----ld------------ Prop. Line ...1©.............. �N <br /> LEACHING LINE [ ] No. of Lines --------/------------ Length of each line_______` __ �a___ Total Length -__t� _ <br /> 'D' Box Type Filter Material Jz R``_A_.Depth Filter Material -----d?o..r__.......................... <br /> Distance to nearest: Well ________`'_________ Foundation ------/4------------- Property Line ----- --.--- <br /> SEEPAGE PIT [ ] Depth _______. ---------- Diameter ________________ Number -------.-------------------- Rock Filled Yes ❑ No iQ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------.----------------------------- Date _________________________________) <br /> Septic Tank (Specify Requirements) ---- --------------- -------------------------------------------------------- ------------------------------------------- ----_--_-- <br /> Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- <br /> ------------------------- ------------ ---------------------------------------------------------------- ---- --------------------------------------------------------------------------------------- <br /> (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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - � �`---- --"f--! ------ah--------------------------------------- Owner <br /> G -- -- ---- --------------------------------------- Title ------ cd'_ uEtrzcP=�L ----------------------------- <br /> Of other than owne�li <br /> FOR DEPARTMENT Up 9,NkY,/ <br /> APPLICATION ACCEPTED BY --------------------------------------- DATE .------------------ <br /> BUILDING PERMIT ISSUED ---------------------------------- - ---------------------DAT y-------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------ ----------------------ay -------------------------------- -------------------- -----------------=-------------------------- <br /> - - --------- -- - <br /> --------------------------------------- ----------- ------------------------ ------------------------ I--- -_-- -------- ---------- --� ------ -- --------------------------------------- <br /> __________________________________________________________-------------------------- ____________ ____ ____ __ ---------- ------ <br /> ____y-______-____r� __ _ __________.�_.. <br /> Final Inspection by: --- ------------------------------------ ---- --------------- ------- ------* -----Date --- -=1 <br /> - ------------------ <br /> SAN JOAQUI ' LOCAL HE D CT <br /> E. H. 9 1-'68 Rev. 5M <br />