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6 S, .e-rev I r` I 2- 1 c7 <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ...7............... <br /> ...................... ..... This Permit Expires 1 Year From Date Issued <br /> Date Issued ..:3.-A".7y <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 .....3 a .. K�Ss°°� F4 � I b 3 Z CENSUS TRACT <br /> Owner'sName ..�.f.A.c�:..........C.e x............................................ ... .. . ..................Phone $3S`�"S a``#'f...... <br /> Address ..........�.p'...................................I..............•. •........................... City ...T.�!�G�.......................................................... <br /> Contractor's Name .....A.4..l.._�/��..' ..�c. .. <br /> ........................................License # Phone .,P3e:A�fQ....-- <br /> Installation will serve: Residence f'Apartment House Commercial ❑Trailer Court 0 <br /> Motel ❑Other ............................................ pGJ <br /> Number of living units:......... Number of bedrooms ...!.......Garbage Grinder ............ lot Size ..�c%_k_� ................ C <br /> Water Supply: Public System and name ................ .......................Private ❑ � <br /> Character of soil to a depth of 3 feet: Sand 0 Slit❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 <br /> Hardpan ❑ Adobe❑ Fill Material ............ If yes,type .......................... <br /> (Plot plan, showing size of lot, location ofsystem 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................................................ liquid Depth .......................... <br /> Capacity Type Material...................... No. Compartments ......................W <br /> Distance to nearest: Well ....................................Foundation Prop. Line <br /> LEACHING LINE [ ) No. of Lines ........................ Length of each line............................ Total Length ............................ p <br /> 'D' Box ............ Type Filter Material Depth Filter Material .............. G <br /> Distance to nearest: Well Foundation ........................ Property Line ........................ 6 <br /> SEEPAGE PIT [ ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No Q <br /> Water Table Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well .........................Foundation Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ......... . Date ..........J 8 <br /> Septic Tank (Specify Requirements) ------ �� c.......................................... ...... _..:...._..._.. .............. <br /> Disposal Field (Specify Requirements) ....... ........'r7�k_l'�.X..A�Z ..i...................................... <br /> -------------------------------------------------------------------------------------------------------- --------- --------•------------ _------•------..-.._ ,_. <br /> ..............I--.. ......... ..........------•--------•---•--....-•---•-----...--•------•-----...---•----••----•-•---......----•-•---....................---••---- <br /> (Draw existing and required addition on reverse side) <br /> I 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 /> "1 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 subiec o orkmaann'' Compensation laws of California." <br /> Signed .... ..r A`--=�-�.....----••-•---...---•---..................... Owner <br /> By ...........................................................................................••-......... Title ........................................................................ <br /> (If other than owner) <br /> FOR DEPARTMENT/,US ONLY, <br /> APPLICATION ACCEPTED BY.................... DATE <br /> BUILDING PERMIT ISSUED ..............................•-•-............ •----... ................. .. ..... .. ...................DATE ........................................... <br /> ADDITIONAL COMMENTS .................................................. ................... <br /> .............. <br /> .......................................................................................................................................................................................................... <br /> ..........................•---........-••...................... ;........••...... .......................................-•........... ............._.............................•... ...... <br /> --•-•....................•-•-.................. .....................•--••-........................................._.......--- <br /> ,77 <br /> Final InsectionbDate .. :( .......... .. ...... <br /> P Y <br /> SAN JOAQUIN LOCAL HEALTH:DIST <br /> E. H.13 241-'68 Rev. 5M 7/72 3 M <br />