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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT' '° <br /> Permit No. 'j-Z- - <br /> ----- 3 7 <br /> ' {Complete in Trip icate <br /> ll/-------------------------- <br /> 191-7 <br /> This Permit Expires 1 Year from Date Issued <br /> Date Issued -.y--------------- <br /> --------------------------------------------------------- <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 �ZL_.� � - <br /> -- C7f ,�--- / ..--e19-------------CENSUS TRA4T --f---------------------- <br /> Owner's Name ;/,/ ---- --- -------------------- ------------------------------------- <br /> -------------------Phone <br /> Address ___ ..��144 . city ------------------------------- ------- <br /> Contractor's Name -,r------------------------- --- ------License #1;?7 ------ Phonejj;W_�'�1����c�b <br /> Installation will serve: ResidenceA Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number.of living units:--- ----- Number of bedrooms -A------ Grinder ,/,,v&.. Lot Size.-l____ —------------.---•---- <br /> Water Supply: Public System and name ------------------------------------- -------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay E] Peat E] Sandy Loam ❑ Clay Loam ❑ <br /> Fill Material ------------ If yes, type----_----------------------- <br /> Hardpan E] Adobe <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 f ] SEPTIC TANK:[ ] Size---------------------------------------------- - Liquid Depth ------- ------------------ <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 --- --___-------.-_------ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------•.-------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---------------.-------. <br /> SEEPAGE PIT ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water.Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ------ ----------------- ------Foundation --.-.----------.---- Prop. Line -----.....--------_-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------y----- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) - ------ --------------------------------- - /-----------------------------------�---!--i-- <br /> -----------------•--------------------------- <br /> Disposal Field (Specify Requirements) dx-- -_-- --f- � / 0 Af__;1V j2"-------- <br /> --------------------------------------------- <br /> --------------------------------------------- <br /> -------------------------------------- <br /> {Draw existing and required addition on reverse side) <br /> I 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 /> "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 beco/subjeman's Compensation laws of California." <br /> Signed -- ---- ---------------------------------------------------- Owner <br /> By ----------- --A----------------------------------------------- Title ------------------------------------------ ----------------------- <br /> ner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------ <br /> E- -- ��-------------- <br /> --------------------------- -------------------- ----------------. DATE ----� � ---------•--- <br /> BUILDING PERMIT ISSUED ------------ ------------------ -- ----------------- ----------DATE ----------------------------------------- <br /> ---------------------------------- - <br /> ADDITIONALCOMMENTS ------------------- - ----- -------------------------------------------------------------------------------- <br /> ---------------- - --------------------------------------- - - -----T r--------- / - --Z------------------- -- - ---- -------------------------------------- <br /> - 1 = <br /> FinalInspection by: --- 3--_ _ _ ------------------------- --------------------- ------------ Date -- ------------------------- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />