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EOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------�- - 4----- ------ Permit No. _�`�-3 S3 <br /> ` ' - (Complete WTriplicate) <br /> ------------_------------------ ------- This Permit Expires 1 Year From Date Issued Date Issued .6--- <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 ` _ �om------ fir 'C IJ_ ------------------------------ - --CENSUS TRACT -------------- ----------- <br /> Owner's Name -----AARI 1� _ <br /> Phone <br /> - <br /> Address __..� � CitY ����- <br /> - -------------------------------=----------------------------------------------- --------------------- <br /> Contractor's Name -- ___�7 / -------•---------License #f ? ---- Phone <br /> Installation will serve: Residence l] Apartment-House,0-Gorrimercial :OTrailer--Court ',❑ <br /> Motel ❑ Other --------------------------------=-----=------ <br /> r <br /> I Number of living units-----l----- Number of bedroom,5 -- _--Garbage Grinder _,,1/1/0__ Lot Size -------------- <br /> Water Supply: Public System and name ------------------ �41/_G.----------- --- --------------------------------Private El <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ lPeat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe7 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 /> t 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 /> I CapacitY1------------- ------`Type ------------------ Material---------------------- No: Compartments ----- <br /> Distance <br /> --- .01 <br /> Distance to nearest: !Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> t LEACHING LINE [ ] No. of Lines ------------------------- Length of each line --------------------------- Total Length ----------- ___________- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -----------------------.--------_---- ------ <br /> Distance to nearest: Well ----:-�__:_------------- Foundation -----------Property Line --------------- 0 <br /> SEEPAGE PIT [ ] Depth __ ______ _________ Diameter ---------------- Number ------ --------------------- Rock Filled Yes ❑ No 10 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------- <br /> 1 <br /> Distance to nearest: Well ------------------------ ------Foundation -------------------- Prop. Line --------------------- <br /> F I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ___________-___________----------_) <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------- -----------------------------------------------I---------------------------- <br /> Disposal <br /> -------------------------- -----------------r---------------------------- <br /> Disposal Field (Specify Requirements) --------.va___ �� L�fy' - - -- - ��w---��-------- ;7-5---- e_,Y 3 <br /> -------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----- L------------------------------------------------------ -------------------------------------------------------------------------------------------- <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 /> "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 /> ;t <br /> Signed - ------------------------------------- ' ------ ----------- Owner <br /> F BY ----- - I -- -- - - -- ------ =----- Title ------ <br /> {If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> 5— <br /> APPLICATION ACCEPTED BY - ----- - - ------ -------------------------------------------------------------- DATE --- 7-3------------- <br /> BUILDING PERMIT ISSUED ------ - ,5 - -------------------------------DATE ----------------------I----------------------------------------------------------------------- <br /> - <br /> ADDITIONAL COMMENTS ------r .---®`- - 'S. V <br /> -------- ----------------------- --------------------------- ---------------------------------------------------------------------------- --------------------------------------------- <br /> ------------ ------------------- -------------- -- - -- - - -- ---- --- <br /> Final Inspection b <br /> ----------------------------------------------------------------------------- ------ <br /> ----- --- ------- <br /> pY= ------------------------ --------------Date -� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M m pkI <br />