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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT----- Permit No: -4-9--&1-7 <br /> (Complete in Triplicate) <br /> ------------------------------ -------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued -_S� l�---� <br /> - - _---------- --------_------_----- <br /> 4 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 Ordnance No. 549 and existing Rules and Regulations: <br /> �x �`e" <br /> � JOB ADDRESS/LOC N ---�-�- -�----- - - - --- - - - --- -- - ------------------------ CENSUS TRACT -.------------------•----- <br /> W 4 -------'--------- ------------- - -----P one -----------------------------•------ <br /> Owner's Name .- .�C-�-�r------- ----------- <br /> �7 I * --- <br /> Address - !'`f � 1�° -- City f -- <br /> i B <br /> Contractor's Name .----- - - - --- -cS1��' ►"(--tl icense# --1�dt- zf-ylshone ------------------------------ <br /> Installation will serve: Residence . Apartment House-E] Commercial:❑Trailer Court :❑ <br /> i <br /> t Motel ❑ Other -----------------------`--------------------- <br /> Number of living units:------- Number of bedrooms -__?"�Garboge Grinder ------------ Lot Size -----/4?—#✓ ------------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------- - =---------Private <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam Clciy 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 /> t <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> r PACKAGE TREATMENT SEPTIC TANK I ] . Size------------------------------------------------ Liquid Depth ----------- <br /> ------------ <br /> ---------- <br /> -Capacity -------------------- Type -------------------- Material---------------------- No. Compartments� ---F { psntW :--- d - rne -_------ <br /> -c-:--1-------- <br /> ------•-- �cQ, <br /> - Dtl _ a <br /> Q <br /> jzst <br /> [ V <br /> LEACHING LINE [ ) No. of Lines ------------------------ Length of�eacl-line��-�--------------�------ Total Length -.-.__-- <br /> :-�-_-:�------ <br /> 'D' Box ------------ Type Filter Material-------------------Depth--Filter Material ------------------ .--------- ------- <br /> Distance to nearest: Well ------------------ --- Foundation -------- ---------------- Prope" Line_--___--------- ..-_.--- <br /> I <br /> - -,� �- ~ <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter Number __ RSck Filled Yes '❑ No 0 <br /> Water Table Depth ----------------------------------------- Rock Sizer--------------------------- <br /> Distance to nearest: Well -------------------------E'------------Foundation -------------------- Prop. Line---.-.......�-------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------- =Date -=- ----------------------------- t <br /> k <br /> Septic Tank (Specify Requirements) -------- -- ----------------- -------------"--------- -- ----------=---_-------------------:-----------------_•----------------•-�------.. <br /> Disposal Field (Specify Requirements) ---- .? - (P " - '' # <br /> ' 3 <br /> ' --------------- - ------ <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 16.n Jo quip <br /> 11 County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.District.1"me owner or licen- <br /> sed agents signature certifies the following: I tt <br /> "I certify that in the performance of the work for which this p�rmit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation ZEPA1TIMENT <br /> alifornia." <br /> Signed ------ --------- -------------------- - - --------- - ---------- Owner <br /> �� --------- -Title -------- ` ----------------------------- --------- ----------- <br /> (lf other than owner) <br /> FOR USE ONLY <br /> APPLICATION ACCEPTED BY ------------------- <br /> x ------------------------------------------------ DATE -- <br /> - <br /> BUILDINGPERMIT ISSUED ------- ------------------------- --------------------------------------------------------=--------------DATE ----------------------=----------- ------- <br /> sADDITIONAL COMMENTS -- ----------------------------- -------------------- -------------------------------------------------- F-------------{--•---------------------- <br /> f -----------------------------------------_----_---.- ---------._--_-____ _-----_--_----__--------_-_---_------_------------------------------------------------------ <br /> [E---------------------------__-_----. <br /> ---------------------------------------- ----- ------------------- -------------------------------------------------•----------------`----------------------------------------------.----_--_--.__.. <br /> ________________________ - -.---____-___---- _----- �- K• _ -.---_--_-------_-_ <br /> r Final Inspection by - ------ -------- ----------------------=-------- ------•---------------------- <br /> ----------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r,.- . j <br /> E. H. 9 1-'68 Rev. 5M. <br />