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FUR OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT r <br /> :...._..._ <br /> ..........I—.. (Complete In Triplicate) Permit No. / .__.•._.._...... <br /> ...........................I......................... This Permit Expires 1 Year From Date issued <br /> Date Issued _1� <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 Ordinances No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ...11+�� ..:.1.�/ ._... _ _ ,7...........................CENSUS TRACT ..........-............... <br /> Owners Name �..r_..C� A,6h -_J-........................................... <br /> ----------- ..- ...... ............... - 1..�..... <br /> Address ...._.. 3 w�'� / ' C.° = ----------`D-�-----•--•---- - ........ City ...��?.f< i' _..._��f✓.......... .................. <br /> Contractor's Name ------_ <br /> -Az/.4_4��------•-------•----_-.................License # Phone a �������a <br /> Installation will serve: Residence§4 Apartment House 0 Commercial❑Trailer Court <br /> Motel ❑Other --------------•----------- ---•-- .......... <br /> Number of living units:_--: Number of bedrooms ------Garbage Grinder ------------ Lot Size _--------_-----_---- ................... <br /> Water Supply: Public System and name ----------------------------------------------------------------_ ---------- ........... ...................PrivateO <br /> Character of.soil to a depth of S feet: Sand o Silt o Clay ❑ Peat❑ Sandy Loam S( Clay loam ❑ <br /> f <br /> Hardpan ❑ Adobe ❑ Fill Mnterlal ............ 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'-]S < Size.........................:.. ..........•------- Liquid Depth .......................... <br /> ..,.,�� <br /> Capacity ---------/-------- Type -----_------------ Material-------------------- - No. Compartments ...................... <br /> Distance to nearest: Well ------------------------------------Foundation -------------------... Prop. Line -._..-____---------- <br /> LEACHING LINE ( ] No. of lines ----------•----•-------. Length of each line.----------------_---------- Total Length ............................ 6 <br /> 'D' Box,---.--..-_ Type Filter Material ....................Depth Filter Material --------_ .............................. <br /> . � <br /> :t? - <br /> Distance to nearest: Well-------- ................ Foundation ..--------- ----------- Property Line ........................ <br /> SEEPAGE PIT [ ) Depth --------------- _- Diameter ._.............. Number ---------------------------- Rock Filled Yes ❑: No 0 J <br /> Water Table Depth ...... ............ ---------- ----------_----Rock Size ................................ <br /> Distance to nearest: Well --------------------------•-------------Foundation .................... Prop. Line ...................... G <br /> REPAIR/ADDITION IPrev. Sanitation Permit# .......___:............................. Date __:..._.._...--.----------------_) tf► <br /> SepticWank (Specify Requirements) ............................. ........... ........................................... ..............................................--........ <br /> Disposal Field ISpecify Requirements) ....�; c�y�-�U..... L ----:- .----_----`-------t--------- ------•-------------------- <br /> -•--------------------------------------------------- ® -- 5 ............. <br /> --------------------------------------1- -- ------------------------------------------------------------------- ------•-•------•........................................_.......... 11 <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 <br /> as to become sub" ctto rkrnan's Corsrpensation laws of California." <br /> Signed . - - ............................I— --•------------------- Owner <br /> By ------------------------------ ---------- ---------------------- ----••----------------------------- Title - ------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----. . . . <br /> - _ .4. ------------------------------------------------------------------­1-------- DAVE .. .. <br /> BUILDING PERMIT ISSUED ------ ---------------------- --------•-------••-•----•------•-------------------------._DATE <br /> ADDITIONALCOMMENTS ------------------- -------------------------------- -------•---_------- ..................-------- .............:........... ....... <br /> ------------------- ------------------- -----------------------------------------------------••--• ------....-•-------•--------------..-.-------....---.-....---•....--------•---...__.._.._.---•-••--•- <br /> -. •------••-------------- ---- - ---rd- -- ----•-•- ... . ...----...-----------------.----------------- ........----------......----. -- ...__.......----------- ---------------- <br /> --------------- ----------------------------• . <br /> Final Inspection by -----...---- Date .-_. .................. <br /> EH 13 24 1-68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />