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POR OFFICE USE: � -` Is <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------- {Complete in- Awl Permit No. <br /> -------------- , c <br /> Date Issued <br /> _ <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 i <br /> described. This application is mad I)in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> I I CENSUS TRACT ------ a------------- <br /> JOB ADDRESS/LOCATION .- SFr. _1 c�- -- -- "Ji C_ _2 uEz <br /> Owner's Name - -----------301--li�2-'---0QR�r _ _,_.�Y2 <br /> Phone3$�`.7 cf`).�_... <br /> Address - Mk ----------------------------------------- City l2 GY--------------------------------------------------•-•------ <br /> Contractor . Name -- ----------------0W-J-aVCt----------------- - ----------.License # ---------;-------------- Phone ------------------------------ # <br /> Installation will serve. Residence (Apartment House-E] Commercial:❑Trailer Court ;❑ ! <br /> . t <br /> Motel ❑ Other ------------------------------------------ e <br /> •-- -qtr <br /> Number of living uri ----- Number of bedrooms ----_°02__----Garbage Grinder ------------ Lot Size _- x-..tCaO-------------------- <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------- -------- ---------------Private 1?1� <br /> Character of soil to a'depth of 3 feet: Sand Silt❑ Clay [I Peat E] Sandy Loam E] Cl Loam <br /> 'F] <br /> t , <br /> Hardpan F1 Adobe F-1FillMaterial ------------ <br /> If Yes,type ------------------------ -- <br /> i <br /> [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side') <br /> I <br /> NEW INSTALLATION (No septic tank or seepage pit permitted if public sewer is available wi#hin 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK f ] Size------------------------------------------------- Liquid Depth .._.-.._..-._-------_----- <br /> CapacitY __J--------------- Type -------------------- Material-------------°-------- No. Compartments -------------•-------- <br /> Foundation -------------- ----- Pro Line -------------:-,------ <br /> - i Distance to nearest: Well ------------------------------------ - p• <br /> LEACHING LINE [ } No. of Lines ------------------------ Length of each line---------------------------- Total Length ------------ --------------- <br /> 'D' Box --- 1------- Type Filter Material ---------------------Depth Filter Material ------------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation "---------------- -.--- Property Line ---------.--•------_-.-- <br /> SEEPAGE PIT [ ] ; Depth ...._;_ _'---------- Diameter --------------- Number ----------.--------------.__Rock Filled Yes ❑ No :0 i <br /> Wa.terj(Table Depth ------------------------------------------------Rock Size --------------------------- <br /> Dis�ance�o nearest: Well ----------------=--------- -------•-_-Foundation ----------------- -- Prop. Line F - n <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------- _-=------- --- Date ---------- _-----------------) i <br /> ` Ott-- _ !'�Y11 G ' ------------- -- ------------------I------'----------•---------- <br /> Septic Tank (Specify Requirements) ---------------I----- - -;------ = I <br /> p y I <br /> rnents) ----------n�P__-----���.h-_I_in�. - ---��-�--�`.-lQ-�i�---pt----------------------------------------------- <br /> is <br /> ---------- --------------•------ -------- C- <br /> i --------- --i--------------------- `a <br /> Dis osal Field (Specify R�=,wire <br /> --------------- -------- <br /> --------------------------------------�------------------------------------------------------------- (. <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 four which-this perm fi iss ed, I shall not employ any person in.such manner <br /> asto become subject to Workn s Compensation.lawsof <br /> Sign -------------- Califor <br /> Ownel <br /> Title --- <br /> ------------------------------------- --------------------- <br /> ---------------- <br /> ------------------- <br /> (If other than ow r) <br /> 3 <br /> � FOR DEPARTM T U E ON LY <br /> / 7oi <br /> APPLICATION ACCEPTED BY_----- ------------- ---- ------- ------ - _,; ---- - ..... DATE --.--------------------- <br /> _. �. .... . -�-- ---DATE "----------------- ------ <br /> BUILDING PERMIT ISSU5D". - __ i ------ <br /> ADDITIONALCOMMENTS ------------------------------------------------------•--------------------------------- ------------------------------------------ ---------------- <br /> ------------------- -------------------------- ------------------------------------------------------------ ---------------------------------- ------------------------------- ---- <br /> -- ---- ¢ -------------------------- ----------- ---- -- ------ <br /> ------------------------------------- l <br /> ---------- <br /> ----------------------------------------------------=1 --------------------------------------------- --------------- <br /> Final Inspection by ' -.a - ----------- <br /> ------------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALT DISTRICT <br /> I'' E. H. 9 1-'68 Rev. 5M <br />