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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r <br /> .................................... Permit No./�5 v 7 3 <br /> {complete In Triplicate) <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> Date Issued .�0........ <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 and Regulations: <br /> JOB ADDRESS/LOCATION ...../,/, ,�..--_`./..ftp----.ski._A !qV.........................CENSUS TRACT``.......................... <br /> Owner's Name .�__. �/11.G�._.......... Yom:7 V .10./ <br /> ...... .................................................................................Phone ....... .. ....... <br /> Address .......6'p-_4 " C-4--.0t,----------v.�-----------_---_-----. City ---0,&W.Tel..... `�._--_-_--•-------...- <br /> Contractor's Name -.---- •-�l./�-�,��,----------------------------------------License # A/'*65_6_7VZ2_. Phone <br /> Installation will serve: Residence f'Apartment House 0 Commercial❑Trailer Court 0 <br /> Motel ❑Other -------------------•------- ............--.. <br /> Number of living units:..-_ Number of bedrooms ------------Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public Systern and name -------------...-..................... ..-.-•._.--.....--------.----_..........__...._.....Private <br /> Character of soil too depth of 3 feet. Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam El 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK f j� Size-------------___--_---------_------..---- Liquid Depth .......................... <br /> Capacity -•-- Type .................... Material-----...................... No. Compartments ------_---_---_- <br /> Distance to nearest: Well ---------•--------------------------Foundation ----................._ Prop. Line ......................-. <br /> 1 <br /> LEACHING LINE [ ] No. of Lines -----------------------• Length of each line-------------------_------ Total length .... ....................... � <br /> 'D' Box............_ Type Filter Material ....................Depth Filter Material _______._._.................................J <br /> .:� t- <br /> Distance to nearest: Well.......................... Foundation ........................ Property Line ........................ i <br /> SEEPAGE PIT [ ) Depth. ..................... Diameter ......... Number ............................ Rock Filled Yes ❑ No ❑ J <br /> Water Table Depth ................ -•-•-------- ..................Rock Size -----_----------•---- ...... U <br /> Distance to nearest: Well ........................................Foundation .... ............... Prop. line ...................... 0 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --...--- -------------------------- Dote ----_--------_ ---------_-----) t/► <br /> Septic Tank (Specify Requirements( .............. ............................................. --------.................--•-- ....... ........I....................... <br /> Disposal Field (Specify Requirements) --._� ..... 's�: _..,_. ----------- �--------e=....••••........................••-- <br /> ----------------------------------------------------- cv - � �i / r ---------- <br /> ........................ <br /> - - - --- ---- - - <br /> (Draw existing and required addition on reverse side) S <br /> 1 hereby certify that I have prepared this application and that the writ 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 /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become sub' ct to rkmon's Compensation laws of California." <br /> Signed - c. <br /> ..-'------ - -- ------•------•--•• --••----------------------------------- Owner <br /> By --------------------•------------••---- -----------• --•--•----•--------------------------•------------ Title ---------------------- <br /> (lf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... .... . .... DATE .---..._ .. .. �.--•---.-------------- <br /> BUILDING PERMIT ISSUED ------ - -- -••-----------------•------ -----------------------------------------....................DATE -------- ---••--•---• ------••---..-....._. <br /> ADDITIONALCOMMENTS ------•---------------•---------.----_----••-----------------.-.---•--•-------- --------------------..------ ------•--------------- ------------------------- <br /> --•---• --------- ---•---- --------------•-------•-----------------------------------------•-----....-----...----•-----------••---•------••-.----- <br /> - -------------------• _...-....-- <br /> -•-------•-•----- -------------------------- -------•--- ----- <br /> finalInspection by: -..-------- -----•..................................................................._.Date - ..�0- ��--.---I....... <br /> Mf 13 2L 1`68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT' 8/74 3M <br />