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F(MR CE USE: APPLICATION FOR SANITATION PERMIT <br /> - l w <br /> ------------------ •--------------------- Permit No _ ' <br /> ;Complete in Triplicate] 7 7 �.� <br /> ----------I------------ --------------------------------- <br /> -� � ^ , - _ Date Issued -�----�yy <br /> p� <br /> --_-__�0'�' -- _5'�s::�_--�--_,_-_�_---_--{-_: _..-a�•' This Permit Expires 1 Year From Date Issued <br /> ? <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 �anyd' Regulations. { <br /> ♦'C-�`�-� o..7r a L�C.�r.�-C3/ry-!i/"�'�/� � <br /> JOB ADDRESS/LOCATION :'_�.� - <br /> ��U���/�j' ��__.�dr�---����s��.__�'�ru -JYI�/10ENSUS TRACT ---------- ----------- -- <br /> Owner's Name _ Vfh�1 f�.S^ = Phone3'_ .14. <br /> Address _�_ � � G ! zt'- --------------- ------------ Cit _��� �G--`- ----------------------------------------•--•--- <br /> Contractor's Name -------- ---------------------------------License # / ` ------e__ Phone <br /> Installation will serve: Residence Apartment House❑ Commercial:❑Trailer Court '',❑ <br /> Motel ❑ Other ----------------------=------------ -------- <br /> Number of living units:---.------ Number of bedrooms ---9----Garbage Grinder ___________ Lot Size -------------- <br /> Water Supply: Public System and name ----------------------•----------•----------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'r Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe-❑ 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: JNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK'f ) Size_ --- ---- Liquid Depth --�? -....------, <br /> Capacity AACY ----- Type Material r.�� �-�' C?l�fo. Compartments --27=--_:____ <br /> Distance to nearest. Well ------ --------------------Foundation ______ Prop. Line ___6-------:--------- <br /> i. <br /> LEACHING LINE [ J No. of Lines ____r_?-------------- Length of each line_____.�70------.------ T6tal Length _l- - __----_______.' <br /> 'D' Box __/-_._.__ Type Filter Material -___-__________. __Depth Filter Material --------------------- <br /> Distance to nearest: Well _----- d---- Foundation d __ Property Line /-.._- ~ <br /> __ _ ________________ ____-__...f <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------. Number ---------------------------- Rock Filled Yes ❑ No i❑. <br /> WaterTable Depth ----------------------------------- -----------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -----------------.--. Prop. Line -------.---------..... 1 <br /> I �REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________._______________------_---) <br /> SepticTank (Specify Requirements) ------------------- --------------------------------------------------- ------------------•--------.----------------------------- <br /> DisposalField (Specify Requirements) ---------------------------------------------------------------------------------------------=-----------•--------------------------- <br /> ------------------------- ------------------------- -------------------------------------------------------------=---------- --------c----- -------------------- . <br /> (Draw existing and required addition on reverse side) <br /> 1 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-, E <br /> as to become subject to Workman's Compensation laws of California." <br /> i <br /> Signed - -- - --- ----- ------ ----------------- Owner JBY ------ (if__ R- - --- �e�--= - ------------------ Title ---------_------------------- ------- -------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- - --- ---------- -- --,------------------------------ <br /> --------------- DATE ---- �/r-------------- <br /> BUILDINGPERMIT ISSUED ------------------ ----------------------------------------------------- -------------------------------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------ ---------------------------- ---------------------------- ------------------------ ---------— C <br /> c.: <br /> ------------------------------------------------------------------------------------------------------------------------- --------------------------- --------------------------------------------------- <br /> -- -- - ----------------------------------- - --- - - -- <br /> ---- ------= ------ <br /> Final Inspection by: --------------- - - - -- ------ -- ---- - ---- -Date ---------- -- -- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E- H. 9 1-'68 Rev. 5M <br />