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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .......... . (Complete In Triplicatel Perm-it No. <br /> .............................I.......... . <br /> I 'A Date Issued <br /> ................. ................... .............­ This Permit Expires I Year From Date Issued <br /> � AppliCatlOhll'hereby made to-the San:Joaquin Locbl"Health'Distri i et"for a permit to construct and Insta-i 0..the-1 work herein <br /> described. this application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB �l - 0 <br /> ADDRtSS/LOCA ...... <br /> TION <br /> . . . .... . -----......`....r-._....-..-........................CENSUS TRACT) .......................... <br /> Owners Name ..... V ....... ......... ... ..........r,........................... Phone .4161_;�'PT lfz <br /> • 7- -----I------- <br /> Address -y- 4 . .......... ............ ... <br /> ... WCity <br /> . <br /> ............................... <br /> .......... <br /> Contractor's Nome ...............................License #.7S..y_3y3.........Phone <br /> Installation will serve Residence%Apartment House f:] Commercial oTrallor Court ❑ <br /> Motel0 Other.................. ......................... <br /> Number of -living units:....... INuniber of bedrooms ............ 9 ...._........Garbage Grinder ............ Lot Size ./12?7.X 3 C) <br /> I1 . ........................... <br /> Water Supply.. Public System and name ----------- .........................._._..........................................................�i <br /> ....Private <br /> Character of o11 fo—dldip-tfr6f 3-f4fil Siincl—OSIIVCj Clay�[] Peat 0. Sandy Loom C] Clay Loom [3 <br /> Hardpan 0 Adobe p Fill M6terlal ... ...... If yes,type............. <br /> Mot plan, showing size of lot, loccition of system In relation to wells <br /> 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 feitl <br /> PACKAGE TREATMENT [ ] SEPTICITANK fSize.±!--, ......................•__...••..I...I I I <br /> Liquid/Depth;.-......................... <br /> Capacity f ..-- Type ....�_!...........! Material....... No. Compartments ......... ............ <br /> q <br /> Distance. to nearest: Well .........I..........I...............Founflatioit'_...�-.�..... Prop. Line ............... ...... <br /> - j <br /> LEACHING INE No. of Lines ........................ Length Of each line.__.._........ ..:.J <br /> Total Length ........................ <br /> V Box ...... Type Filter Material .... ..............Depth Filter, Material .......... <br /> Distance to nearest: Well ....­................. <br /> I Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT f j Depth --------- -..- -I E <br /> ..... Diameter ......... Number ... ....................J.. Rock Filled Yes E] N00 <br /> Water Table Depth ...............................................Rock'Size ............... ................ <br /> if 'ilk _-, - <br /> Distance to nearest. Well ......_........_.....................Foundation ............!.t----- Prop. Line ...................... 01C, <br /> I or <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .....-•------------------------------------F Date .................. ...... <br /> J <br /> Septic: Tank (Specify.iequirements) --------- ...... ....►.................... <br /> k L�10 I tA I -------------------^................................. <br /> ------------ ....... . ------------- <br /> Disposal Field (Specify Requirements) <br /> . .... ....... <br /> ... .................................... <br /> ----------------------------- -----------­- <br /> ------------------- ....... ........... ........... ----av-1 <br /> i ------------------------------------- ........................ <br /> -----------­-------­ -------------------------------------------­---------­----------- ..........I..............J.............. ! <br /> (Draw existing and required addition on reverse side) ....................................... <br /> I <br /> work will be done In accorclpnce with Son Joaquin <br /> I hereby, certify that I have prepared this application and that the I <br /> County Ordinances, State Laws, and Rules ane Regulations of the San Joaquin Local HeallhDlstrlc!. Home owner or licen- <br /> sed agents signature certifies the foll4wing: <br /> "I certify that in the performance of the work for whits, this permit Is issued, I *boll not employ any person In such manner <br /> as to becom4 subject to Workman's Compensation laws of California." <br /> Signed --------- ----------- I - <br /> ------- ...... ;Z <br /> By --------- <br /> ------------- ------- Jit .......................... ........ ---------- <br /> (If r than ownerl <br /> FOR DEPARTMENir USE ONLY <br /> C_Wt �_ - <br /> APPLICATION ACCEPTED BY ----------- __-­--- --- - -1 DATE . ZAPS-------------- <br /> BUILDING7 PERMIT ISSUED ---------- -------------------- -- -------/-,* ------------------------------ <br /> -----t.............. --------- -------------------------- .............-..,.--DATE .............................. ........ <br /> ADDITIONAL COMffE7TS ------- ...........................•----- l....... ............... ----------------------- <br /> --------------- ---------- ------- ...... --­---------------------­.............................. <br /> -------------------------------------- ---- --- -- ------ ------ --- ----­---------------- ----------­­­.................11....... ----------------- <br /> ............................ <br /> ................ <br /> _- --------/-_-_11_1------------*----- •------------------------------------- ------ <br /> Final Inspection b ............ . ...Date <br /> EH 13 12h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br /> C�o <br />