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FOR OFFICE USE: q2,i, <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------r-------------- - (Complete in Triplicate) Per No. <br /> ------------- <br /> ---------lr---------------------------------------------- Z Z -7 Z <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 permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5/49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ®O 9 --------------CENSUS TRACT � ------- <br /> --- <br /> Owner's Name ---_ _ _ - - -------------C - PhoneIC'71p l ----- <br /> f <br /> Address ------------- /. R-I 54 rl J oID�- _u iy 11'ilc,✓����,� oo <br /> Contractor's Name ------------------ ---------------------------------------.--License # -------- ------ Phone .............................. <br /> Installation will serve: Residence22'Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> A Motel ❑Other -------------------------------------------- <br /> Number of living units:------'/----- Number of bedrooms ------------Garbage Grinder ------------ Lot Sized o40 <br /> Number <br /> Water Supply: Public System and name ------�7_a_'Y17.71'I.._S--y---_15_-------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam <br /> Hardpan ❑ Adobe 21 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 [RZSEPTIC TANK[ ] - -. Size_---------------------------------------------- Liquid Depth ._................. <br /> ._._._ <br /> Capacity ---��As------ Type -------------------- MaterialCompartments ----2.............. <br /> r- m Foundation ---1d --------- Prop. Line _ ..� .. (N <br /> Distance to nearest: Well. .�_�_�________________ <br /> [ ] •�----_--____- Length of each line -- +'�___ � Total Length ,----- <br /> LEACHING LINE No. of Lines ______-. ...-. --�-_-- <br /> 'D' Box ---" -_ Type Filter Material S v cue Depth Filter Material ----- .................................. <br /> Distance to nearest:Well ---L_S_P-60...... Foundation -------L_f'------------ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------------- Rock Filled Yes ❑ No 0 <br /> Water Table.Depth ------------------------------------------------Rock Size --------------- -----_-------- � <br /> Distance to nearest: Well ----------------------------------------Foundation ------ ------------- Prop. Line ....-.....-..........- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date .-----..-------..---------..----..1 <br /> SepticTank (Specify Requirements) -------------------------------------------------------------•----------•---- ------------------------•--------------------------------- <br /> Disposal Field (Specify Requirements) --_-------__ -------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- -------------------------- <br /> ---------------------------- ------ ------------------------------------------------------------- -------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 suA�tor n mpe t' n 1 f California." <br /> Signed --- ------- ------ Owner <br /> BY ------------------------------------------------------------------------------------------------------- Title -------------------------------------------------------------- ------ <br /> (if other than owner) <br /> FOR DEPART T U ONL <br /> APPLICATION ACCEPTED BY------------------------------6_� <br /> - = ^----. DATE ----�" rY -� —--------------- <br /> BUILDING PERMIT ISSUED ------------------------------------ ------ ------ ---- ------ -- --------------------DATE ------------- ...---------..-._..-- <br /> ADDITIONAL COMMENTS -------- --- --6 -----------------------------------------------------------•-------------------......-- <br /> -------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- -------------------------------------------------------------------------------------- -- - <br /> Final Inspection b ------------------------------- Date ------S------- -_---------------- <br /> --------------- <br /> -- - - -- - --- -- <br /> SAN JOAQUIN LOCAL HEALTH ICT <br /> E. H. 9 1-'68 Rev. 5M G <br />