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- FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. --------- <br /> ------------------------------------------- <br /> - This Permit Expires I Year From Date Issued 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/LOCATON ____-_ __-�--__----- ------ ---���✓-__XA°�_ W710ENSUS TRACT Q.5'8"-_Z2v--v- <br /> / <br /> { r <br /> Owner's Name ---- 1------- rr t J---------------------------------- ----------:-----------X�_ <br /> ----------------Phone ------------------------------------ <br /> Address ----------------- .X .7 P` ` '�----- -------------- City --- ---------------------------------------------------.--- <br /> ,fes �_ <br /> Contractor's Namef _-- <br /> -.� f� -- -'jt'---------------License # ������ �----- Phone ------------------------------ <br /> Installation will serve: Res Bence [KApartment House❑ Commercial []Trailer Court ❑ <br /> s <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:------ Numberlofbedrooms ---"___Garbage Grinder ------------ Lot Size _____ --________________ <br /> Water Supply: Public System and name __ _ __ �C,rr,,�� - - _ __________________Private [ICharacter of soil depth of 3.feet: _ Sand' <br /> E]to a de ` <br /> p ❑ __Silt❑. _-Clay. ❑ ..,Peat❑ ... Sandy,Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ SFill Material ----------:_ If yes,type ____________________________ <br /> (Plot plan, showing siz 1 of Ilot, location of system in relation to wells, buildings, efc.• must be placed on reverse side.) <br /> NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) m <br /> _r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ft� ,4 Size-4 ./_Q__. '_ __ _________________ Liquid Depth q_______________._____ <br /> Ca acit ]/ r __ Material No. Compartments P Y -f-t�l�D---- -- Type -��----- -- - -- P --�.............. <br /> Distance to neare : Well -------rvca_--------------------Foundation ......f__Q----------- Prop. Line ---- ___---:- ------ <br /> LEACHING LINE [ lr�No.Lof Lines ------ Length of each line--------J<_P-Q.......... Total Length -------------ate' <br /> ---------------- <br /> �4 ti '' At <br /> I'l <br /> `D% Box __ ______ Type Filter Material __ ___Depth Filter Material ------------------------------______________ <br /> a <br /> Distance to nearest; Well -------I_ V...._..... Foundation ________l_a___________ Property Line <br /> Depth ------1-'---- -- -- �ttn�' ____��-fr1---- Number ------�----------------- Rock Filled Yes R( No I � <br /> Water Table Depth ---------------� r --N..........................Rock Size --------5--" <br /> Distance to nearest: Well __________�_Q_� _�-----------------Foundation -----i_0_t_.--_.� Prop. Line _____fir_.,_.---_.-_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------_------_----------------------------- Date ________-_.___---_--___-:_________) <br /> SepticTank (Specify Requirements) ----------------- --------------------------------------------------------- ---------- ------ ---------------------------- <br /> Disposal Field (Specify Requirements) _______- ' <br /> � 1 <br /> ---------------------------- ------ -----I---------------------------- -------------------------------------------------------------------------- --------------- --------- ---------- ------------- <br /> ------------------------------------------------ --------------------------------------------------------------- ---------------------------------- <br /> ._ (Draw existing end required addition on reverse side) x <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 Son--Joaquin Local Healt�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 subject to-Workman's-Compensation-laws of-California.'!- <br /> Signed9- <br /> ------ Owner <br /> , j <br /> BY -------------------------------------- � YJ Titled ---------------------- <br /> ------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------------------- DATE ------? --------- <br /> BUILDING PERMIT ISSUED ------------------------------------------- ---------------------------------DATE ------------------------------- ----------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> ---------I-------- <br /> ---------•----------------------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - ---- <br /> --- ------------------------------ - ------- - ----- ----------------------------------------------------- ---------------------- ---------------------------------- <br /> ------------------------------------- - <br /> - --------- <br /> Final Inspection by: --- ------------------------------------•---------------------------------------.Date 9_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />