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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> / ! (Complete in Triplicate) Permit No. <br /> 1 .j Date Issued 3: Z3_ jZ <br /> ____ ____________________________._____ - _.____________ I This Permit Expires 1 Year From bate Issued <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 --CENSUS TRACT -----------------_-------- <br /> Owner's Name _ --- ------Phone ------------------------------------ <br /> ef <br /> Ae7-A <br /> Address -------'-----1 - � ------- City � . <br /> Contractor's Name <br /> -- ---------------License Phone -- .—N_Q <br /> Installation will serve: Residence KApartment Nouse❑ Commercial :❑Trailer Court ',❑ <br /> Motel ❑Otther ----- -------------------------------------- <br /> Number of living units:----/----- Nu1.3mber of bedrooms __3___Garbcge Grinder __.______ Lot Size ____________________________________________ <br /> Water Supply: Public System and name 4 = ----------------------------------------------------- ----------------------Private <br /> Character of soil to a depth of 3 feet: Sand•' P ti._Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hard an' <br /> p ❑ 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,) "U ' <br /> PACKAGE TREATMENT { ] SEPTIC TANK:[ I Size------------------------------------------------ Liquid Depth _______._________ <br /> Capacity -- ----------- Typd--------------------- Material-------------:-------- No. Compartments ---------------------- <br /> Distancel.td:.nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------.---__•-----.-- <br /> LEACHING LINE [ ] No. of Lines________ _____ --------- Length of each line---------------------------- Total Length ---------------------------- <br /> At <br /> 'D' Box _"_ f_ Type Filter Material - -------------Depth Filter Material -------------------------------------------- <br /> Distance <br /> ______ _ __________________-_-__-_Distance to nearest: Well ------------------------ Foundation .----------------------- Property Line -_______________________ <br /> SEEPAGE PIT [ ] Depth ___i__ ____' __�Diameter ________________ Number ------------ ---------- Rock Filled Yes (] No ] } <br /> Water Table`Depth ---------�---------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ------------------------.-----------------Foundation -------------------- Prop. Line -----------.----.--_.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _-______.____________________________�_,Date _--_.--___._ ...._-------------- <br /> Septic Tank (Specify Requirements) ------------------ ` - ----j------------------------- -- -------•--------------------------------------------- <br /> Disposal <br /> ------------ -•-Disposal Field (Specify Requirements) ----------•--------------- <br /> ________________________________________________-- '+t____-_ --j _ ' <br /> f' <br /> -----------------------------------_------------_ ---------------------------1----------------------------- ------------------------.------------_---------------------------------.--------.------.-_-_- <br /> "(D�avS existing and required addition'on.reverse side} i <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 /> "1 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 ofCalifornia. <br /> Signed --------------------------------- --- Owner <br /> By --- - Title ` <br /> -- ------------------------ <br /> -- ---- --------------------------------------------------- <br /> (if other th wned <br /> FOR DEPARTMIENT USE ONLY <br /> APPLICATION ACCEPTED BY _-__..___ -- -7 � <br /> . ------ ------------------------------------------------ - - - -------------. DAVE ----'3- ---------?------- - - - <br /> BUILDING PERMIT ISSUED . ---: = DATE <br /> ADDITIONAL COMMENTS -_-- w- rtvr.0 _�uc - <br /> 1r <br /> f = <br /> ------------------------- ---------------.- / ` /i'` s - -------------- ----- � <br /> ------ ---------------------------------- ------------------------------------------------------------------------------------------------------------------------------- ------ <br /> i <br /> ----------------------------i- M <br /> --------------------------------- ------------------------------ -------- -------------------- <br /> ------------- <br /> 2-1 <br /> Final Inspection by: --- — ,� == �. �_.�. �_ -------------------- - ate <br /> --------------------- - <br /> D <br /> .•J� �, SAN JOAQUIN; LOCAL H EALtHDISTRICT . <br /> E. H. 9 1-'68 Rev. 5M G r .d-r <br />