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rl -- An z 0 • <br /> FOR OFFICE USE: �I APPLICATION FOR SANITATION PERMIT <br /> ----------------------------- -------------------- ' <br /> (Complete in Triplicate) Permit No. -��.'� ._. <br /> -------'----------------------------------- ------------ <br /> Date Issued .__c r-_V: <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 heq%)n- <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations:` <br /> JOB ADDRESS/LOCATION / 7--, '�4IN 'd ✓._._J,71_.ay_ %�JY -__CENSUS TRACT ------------- <br /> Owner's <br /> --- ..Owner's Name ------ `--------- -------Phone-tai =-7KWO-----,err"lib <br /> Address0a,t2--i S P �' a1------------- --. city %lr/ic j— <br /> Contractor's Name ---------------------�- _ License # .._ Phonei��/__ "d%�___ <br /> Installation will serve: Residence [4 Apartment Housef❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other --------------------------- -------------- <br /> 6 a <br /> Number of living units:--- Number of bedrooms .__!._:_-.Garbage Grinder __NC,J__ Lot Size _. .._,�'_.�2�_______________________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------•----------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand jn 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..) Ilk <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> [ ] �� tT-_� - Liquid Depth J7—I'K--•------------ <br /> PACKAGE TREATMENT SEPTIC TANK Size X__�yX.�________...._.____.__ <br /> Capacity / _ _ _ Type,r�1FCLWZ__ Materiak:: J1/C/,,, .) No. Compartments. ..2__________________ <br /> Distance to nearest: Well .._C-7 --_______________________Foundation _./2.--.:____._-_ Prop. Line __s _.__________- <br /> LEACHING LINE j/] No. of Lines ------,l-------------- Length of each line.------ 0-------------- Total Length ,_-__`� ............... <br /> 'D' Box ------------ Type Filter Material ___________________Depth Filter Material .______.._.__..__.__-____-___--_-_,__-_.-___ <br /> Distance to nearest: Well ------------- Foundation -----/0__`_.__...___ Property Line ___,rC_ ......_---___ <br /> SEEPAGE PIT [ ) Depth -..._-._..._._._ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ---._._----------N ---Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) W <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ---------------------------«---- --------------•----_ �O <br /> Disposal Field (Specify Requirements) ----------- ------------------------------------- --------------------------------------------------------- <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, I shall not employ any person in such manner <br /> as to beco subje o Wgrkman's Compensation laws of California." <br /> Signed -�m_-__----- ��---- ------------------------------- <br /> ----------------------------------- Owner <br /> BY -- -------------------------------------------- --------------------------------------------- Title ----------------------------------------------_.-------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _______________________________________ _____ . _ _ Z1`1;1011�---------------- <br /> _. ._ ___ <br /> DATE -------- ----------------- <br /> BUILDING PERMIT ISSUED-------------------------- -------- - DATE <br /> ADDITIONALCOMMENTS ------------------------------------ -------------- ------------------------------------------------------•----------------------- <br /> ------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------- --f <br /> ------- <br /> _________________________________________________________________________________________________p... <br />- ................................................................................................ --------- <br /> Final Inspection by: ------------------------------------------------------------ -- ---- --- ----- -- --------_---Date ---�-�����--- ------- <br /> SAN JOAQU ' CAL H T ISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />