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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. --------------------- <br /> ------------- ----------------------------------- (Complete in Triplicate) <br /> ------------------------------------------- w <br /> ----------.-- Date Issued _�-.�-7n <br /> -------------- <br /> This Permit Expires 1 Year From Date Issued <br /> ----------------------------------------- <br /> Application is hereby made to the San Joaquin LIcal 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. 1 <br /> D -- ---CENSUS TRACT _. y ' ------------ <br /> JOB ADDRESS/LO ATION .- � _�r-_-__ _Q-_r_l_Y_I_ { ---------------- <br /> Owner's Name �!LG: - 5 -- --------------------- <br /> - Phone � p. <br /> 4 <br /> ------- <br /> Address ---- �� /1 ` GC1_ --. �`�- <br /> t - i <br /> City Y 1j <br /> i `T�S~ T 1 <br /> Contractor's Name -//�� `` ' = one ___. <br /> _ Ph <br /> installation will serve: Residence,] Apl rtment House❑ Commercial :❑Trailer Court F <br /> i <br /> Motel ❑Other -------------------------------------------- j <br /> Number of living units:.-.--/---- Number of bedrD oms _ ---_Garbage Grinder ------------ Lot Size -------- <br /> Water <br /> ------Water Supply: Public System and name ------------=I"------------------- ----------------------------------•--=-------------------------------------Private J <br /> Character of soil to a depth of 3 feet: Sand 0 , Silt[0] Coy .❑ Peat ElSandy Loam ❑ Clay LoamA <br /> Hardpan Adobe-F1 Fill Material ------------ If yes,type ____________________________ ` ] <br /> .i <br /> N ' <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 <br /> �within 200 feet,) 0\ <br /> [ ] Size_____-_-- 9� g'-'-PJ-�'�'7�quid Depth �_------.- <br /> PACKAGE TREATMENT SEPTIC TANK!D() ,--•-. <br /> C) C�___ Type `_� aterial_�-G� No. Compartments -17.....-------- <br /> Capacity ...... <br /> // j <br /> Distance to nearest: Well Lc^� -----Foundation ____/ _ _ _ _ ___. Prop. Line ---/. <br /> i <br /> Length of each line__-�z7__/ Total Length ` -��.C�---- <br /> Ih LEACHING LINE [1(},. No. of Lines --- _�---___ g �'�/ �� <br /> 'D' Box _, -- Type Filter Material __!__ �---_---Depth Filter Material ----���------------------------------- <br /> �M Property Line ___ - <br /> Distance to�neares: We. __ �-Q foundation '� P rtY <br /> 3� Number ___________ Rock Filled Yes :� No 0 <br /> SEEPAGE PIT [�J Depth __- - ----- Diameter ----- ---------- <br /> Water Table Depth I�-------- ---------------- -----------•Rock Size ------ /---------- <br /> Distance to nearest: Weil -------- - <br /> Foundation Prop. tine ---- <br /> -- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- -------------------------- Date --------------..----.--.----------) <br /> ff --------------------------------- <br /> W <br /> Septic Tank (Specify.Requirements) ----------- °°Ir--------------------------------------------------------------------------- --:------------- <br /> Disposal Field (Specify Requirements) -------- .__ ----------------------------' <br /> ------------------------------ <br /> I� ------------------ ----------­------------ <br /> - w ` <br /> ------------------------------------------------ <br /> - - ______________________________________________ <br /> (Draw existlN <br /> 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 subject to Workman's Compensation laws of California." <br /> Signed ---------- -------------------- - -------------------------------- <br /> Owner <br /> I� Title ----- ----------------------- <br /> --------t--- ---------------- <br /> (If other than owner) <br /> i , <br /> NOR .DEPAitTMENT USE ONLY <br /> .r <br /> APPLICATION ACCEPTED BY -.,, ---- ----------- ------------------------ DATE <br /> ----- <br /> BUILDING PERMIT ISSUED --------- ----------------= <br /> - -------------------------------------------- DATE ----------------------------------------- <br /> ADD1TiONAL COMMENTS -___�'-�t ---- + - -7-� <br /> � I�----------------------------------------------------= ---------------- <br /> i ------------------------------------ <br /> ----------------------------------------------------- <br /> -i}: ----------------- <br /> Final Inspection by: Date <br /> SAN �OAQUIN LOCAL HEALTH DISTRICT L� <br /> E. H. 9 1-'68 Rev. 5M. <br />