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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ................. Permit No: ...7.t!, <br /> X73 {Complete in Triplicate) <br /> ------- This Permit Expires I Year From Date Issued <br /> Date Issued .E?-.r.`.7...:. <br /> Application is hereby made to the San Joa u• Loc ealt6,�Di rict for a�?tper to construct and install the work herein <br /> described. This application is�n�lom ls* tq�rdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA ION �:-.._.r�-...._. " ���'" � ..-........CENSUS TRACT ... <br /> 7 7 ..._..----- ...-.. <br /> Owner's Name - '�'�........ ` '--• .... Phone .... ...._.. <br /> F <br /> Address .-...-.�..3.. .. ....- <br /> ...................... City ......... ...��-.-„ ............................................. <br /> /. j <br /> Contractor's Name l �,q7 /4c 1r� ........ .........License # ........................ Phone ....-----..................... <br /> Installation will serve: Residence4Apartment House] Commercial ❑Trailer Court 0 <br /> " Y Motel ❑Other ................ ........................... <br /> Number of.living units:V 'Number of bedrooms -5........Garbage Grinder ----- ------ lot Size <br /> Water Supply: Public System and name,,�...............•---•--•-------•-••..----------•---•-•-...................... ................................Private ❑ <br /> Choracter of soil to a depth of 3 feet: Sand r Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan (3Adobe E] 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 [ } SEPTIC TANK-[ Size-------------------------------------------------------------------- liquid Depth.—................ <br /> Capacity .................... Type .................... Material...................... No. Compartments <br /> ....:.: <br /> Distance to nearest: Well ....................................Foundation ...._........ ........ Prop. Line .................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line..................:.......... Total Length ....-_.___.................I <br /> D' Box Type Filter Material ....................Depth Filter Material ........................................ -M <br /> Distance to nearest: Well ... .................... Foundation ....- .................. Property Line ...................... <br /> SEEPAGE PIT [ ) Depth .................... Diameter .--._.... ...... Number ..-_.. ...................... Rock Filled Yes ❑ No [ A <br /> Water Table Depth -----------_-• .............................Rock Size ------....--•--•-••-•------••— rt' <br /> Distance to nearest: Well .....................Foundation .............._..— Prop. Line ................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------••-•--•••-------------•- Date ....._.............._._ .......... <br /> G Septic Tank (Specify Requirements) ------------------------ ....................................................................................-•........ <br /> Disposal Feld (Specify Requirements] ..:..... ----•---••--_------------_ ................. _ -••-•-------- <br /> or <br /> .......... <br /> 00� <br /> -- ----- <br /> x...: ---- ------ <br /> (Draw xisting an required addition on reverse side] r <br /> I hereby certify that I have prepared this application and that the work will be done in accordan with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or liven- <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 beta a subject to Workman's Compensation laws of California." <br /> Signed --- ...... Owner <br /> BY ----- ......................... <br /> ................ --.. : <br /> .... -----... : <br /> :.......... ---•---•-------•----.....:-------------- Title .................-........................................ <br /> (If other than owner' <br /> FOR DEPARTMENT,USE ONLY <br /> o <br /> APPLICATION ACCEPTED BY... ... r �-..pF ----�............. DATE .....(0­!r! ... .... <br /> BUILDING PERMIT 155UI±D ..:_ - DATE ..... ................ <br /> _a <br /> i ADDITIONAL COMMENTS ��...... f! ------------------- ------- ------•--------........------ <br /> -_ __ .............. <br /> ,. --• ...........-•-- - -----------------*------- ------•--- Arte <br /> Final Inspection by: _..:..... _ <br /> ... ............................. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> N 13 24 1.'AA Rpv SM _ 7/72 3.M <br />