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FOR OFFICE VSE. APPLICATION FOR SANITATION PERMIT <br /> 4 Permit No. __73 <br /> }Complete in Triplicate) r"� <br /> -------- ----------------------- "� <br /> ---------- ------ <br /> . Date Issued _3n_7 <br /> This Permit ExP fres ] Year From Date 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/LOCATIO <br /> ---CENSUS TRACT -------------- ------ i <br /> � <br /> Owner's Name --- . Phone <br /> Address ------- ,tom ---------------"y---- City --------------------------------- -------------------------------------••-- <br /> Contractor's Name' /(� '`s �� I ------ --- - License # 1,�` `� Phone ' <br /> ZA <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 10 <br /> c <br /> Motel ❑Other=----------------------------------- -------- <br /> Number of living units:... _--- Number of bedrooms --___Garbage Grinder __ Lot Size ----- <br /> Water Supply: Public System and name -------- --------- - ----------------------------------------------------------- Private <br /> Character of soil to ardepth of 3 feet: Sand'[:] Silt❑ Clay ❑ Peat ❑ Sandy Loam .0 Clay Loam ❑ <br /> Hardpan ❑ Adobe*r Fill Material ----- ------ If yes,type ---------------------------- <br /> c.a <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) V <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if/ublic sewer is available within 200 feet,) �! <br /> f-� i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Size_ �,���----- -- Liquid Depth _' - <br /> Capacity "-= Type � �-___ Material" /�f�� 6'-- No. Compartments ---__. <br /> Distance to nearest: Wel! __, """_---------"--`_-_Foundation -'e ----------- Prop. Line -vs.�1 --------- <br /> LEACHING <br /> ----- <br /> LEACHING LINE---[,].---No:-ofiLines P_"`------------------'Length of each line_-------------------- ---- Total Length ------•----.----.----------- <br /> c <br /> 'D'tBox ------------ Type Filter Material ____________________Depth Filter Material ____-___.__"__------_---------- --••----- <br /> Distance to nearest: Well,___________________*_-: Foundation ____---_ ______----._ _,Property',,Line . � ------ ------- <br /> Foundation <br /> PIT -------Diameter Number -__ Rock Filled Yes ❑ o <br /> -- � Water Table Depth ' <br /> ----------- -, `,4---- <br /> --------------Rock Size 1------------------------------- <br /> ---------------- <br /> Distance to nearest: Wellti-------------------`/----------------­-Foundation -------------------- Prop. Line ------- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -.---:----------------- -----------------< i Date <br /> --------------------------------- <br /> I" <br /> ------�-----f- �--t---- <br /> ' <br /> -Se0ic Tank (SpecifyRequirements) 1-4a4iv- <br /> d"bisposal ) <br /> Field (Specify Requirements) ------------------ - -------------------------------------------------• <br /> A.. ; ---• --------- <br /> ---------------------------- <br /> ------------------- <br /> -------------------- <br /> -- z ----------------------------------- ' - <br /> ------------------------------------------- - <br /> ------------- <br /> r {Draw existing and required addition on reverse si e) <br /> I hereby certify that 1 have prepared this application and that. the work will be done in accordance with San Joaquin r <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 issubd, I shall snot employ any person in such manner <br /> as to become subject to Workman's Compe sation laws of California." <br /> c <br /> Signed ------------- --- Owner <br /> Y <br /> G'� F , <br /> BY Title -- ✓ <br /> (if er than own ) - � ""' <br /> FOR DEPARTMENT USE ONLY J <br /> APPLICATION ACCEPTED-BY -- --f- ---- -- --- - -- DATE __ -----""-- •- - ---------- -- <br /> - -------- <br /> DATE -------------•---------------------------- <br /> BUILDING PERMIT ISSUED -------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------ ----------------------------------- <br /> ---------- - ------------------------------------------------------------- --- ---------- --------------------------------------------------------------------------- <br /> ------------------------------------------------------- ----- --------- - - - -- ---------- <br /> y <br /> - --- <br /> Final Inspection by: ---------- = ------------ - - - --------- - --- -- ----- - -- - ------------.Date ----- ----� -------------- ---------- <br /> k SAN JOA 1N LOCAL EALTH DISTRICT <br /> F 14 0 1_'hR Rav 5M <br />