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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------- Permit No. 2 _-l-- - <br /> (Complete in Triplicate) <br /> ---------=----------------------------------------------- <br /> Date Issued <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 <br /> -Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._30100____A'� �aw___h _-_-_____.______________CENSUS TRACT <br /> --•----------- ----------- <br /> Owner's Name55_ ! < ]'y -------------------Phone ----------------------------------- <br /> Address ----------- &llil-e-------------------------•-------------------------------- -------- ....... City ------ <br /> Contractor's Name _ ..-�_. _ - <br /> �nfr/`ta !G fY License #1 . S 6 Phone -7 <br /> _7_ __15 <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ___- -_-C............. <br /> Number of living units:___:____:_ Number of bedrooms ------------Garbage Grinder __________ Lot Size ________________________________________ <br /> Water Supply: Public System and name --------------------------------------------------------------••-------------------------------------•---------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 1 <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 [ I SEPTIC TANK'[ ] Size-----------------------------------.------------ Liquid Depth __________--_----..___---. <br /> Capacity ------------------- Type -------------------- Material------- ---- No. Compartments ....._................ <br /> Distance to nearest: Well ___________________________________Foundation __________-____- ----- Prop. Line ._..._..__........... <br /> LEACHING LINE [ ] No. of Lines _____________________ Length of each line---------------------------- Total Length ------------------------_- <br /> 'D' <br /> _____-____.___..--_.--- _.'D' Box ------------ Type Filter Material ___________________Depth Filter Material _____________-_-___---_-____--.--.-_-------- <br /> Distance to nearest: Well ______________________ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth __________________ Diameter ________________ Number ______________________ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ______-______________________________Foundation ___________________ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------•---------------------•--------------------------- <br /> Disposal Field (Specify Requirements) ______/J ��._____Ael*_6_1te11VA ______ ______4%!1l e________________ <br /> ------------------------------------------ --------------------------------------------------------------------- ----------------------------------------------------------- ---------------------- <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, I shall not employ any person in such manner <br /> as to become sub'ect to Workman's Compensation laws of California." <br /> Signed -----• ` !►f Tif b/It ------ b-`-------------- ------------------ Owner <br /> BY - -- ------------- -------------------------------------------------- Title --------- ---------------------- ------------------------------------- <br /> (If other th <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------------ --------------------------------- DATE ------------------------------------------- <br /> BUILDING PERMIT ISSUED ---------- ------------------------------------------------- -------DATE --------------•---------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------- -----------=------------------ -------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- <br /> ---------------------------------------------------------- ------------------------------------ ------ ---------------------------------------------- -------- ---------------------------------------------------------- ------ <br /> --------------------------------- -----------------------•------------- ---------------•------------------------------- - -----------------------i­j--��?-L Inspection by /t/_c-" Date - '" Z <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />