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FOR OFFICE USE: .� <br /> APPLICATION FOR �1ANITATION PERMIT <br /> ------------------------------------------------- <br /> (ComRlete1n Triplicate) Permit No. �� <br /> ------------- ------------------------- ------ Date Issued v;7,9 ' <br /> --------------------- ----------------_-----------_---- This Permit Expires 1 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 /> / z d'� �i1/• y�U� i3��if'�/ <br /> JOB ADDRESS/LOCATION . -- CENSUS TRACT ----- ------------------_ <br /> Owner's Name -----h r 47----------174A6'YJ ^ --------------------------------------------------------Phone �� CZ 00 <br /> Address -------- -------A/1',�,,�6,vz✓1....-...V k&---------------------------- City _..t~i0i✓7"`A-----e U --------------_------ <br /> Contractor's Name ------•1`. 1�----------- --.License # ----------- ------------ Phone ------------------••----- --- <br /> ---------------------------------------------- - <br /> Installation will serve. Residence ❑Apartment House A- Commercial ❑Trailer Court i❑ <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 a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type _________ ________________ <br /> (Plot plan, showing size of lot, loc of system in relation to wells, buildings, etc. m t be placed on reverse side,] <br /> NEW INSTALLATION: (No septic tank or se a pit permitted if public sewer is avail le within 240 feet,) <br /> PACKAGE TREATMENT f ) SEPTIC TANK f ] Size____________________ _____ ------------ Liquid Depth ---------- --------------- <br /> Capacity -------------------- Type --------------- -- Material---------- ----------- No. Compartments ---------------------- <br /> Distance to nearest: Well ---------------------------- ------F dation ______________________ Prop. Line -___--_________.___._ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each ' e--- ----------------------- Total Length ---_-_______---_----___-__ <br /> 'D' Box ------------ Type Filter Material --- ---------------Depth ' r Material -------------------------------------------- <br /> Distance to nearest: Well _________ ------------ Foundation .------------------- __ Property Line. ____-_.-____-_____--_-- <br /> SEEPAGE PIT [ ] Depth ___________________ Di er ---------------- Number ---------------------------- k Filled Yes ❑ No <br /> WaterTable ------------------------------------------------Rock Size ----------------------------- - <br /> Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ---------------------------------- <br /> Septic <br /> _______--.--- _________________-Septic Tank (Specify Requirements) -s---------------------------------------------------------------------- - ... <br /> Disposal Field (Specify Requiremeklt;) ___ <br /> A/b <br /> - AJciJv `�_6���y / /_ -1'7G �� D Z cuoo <br /> ----------------------- / ------ -- -----------------------------------------------------------------------------------------' <br /> -J--f--O--- <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 become subject to Workman's Compensation laws of California." <br /> Signed / Owner <br /> By Title -4 ".----------------------------- <br /> ------ ----------------- <br /> (If other than owner) , <br /> FOR DEP MENT USE ONLY <br /> APPLICATION ACCEPTED BY _.__. _ __ - DATE ./� ._z.7____ _ ............. <br /> BUILDING PERMIT ISSUED -------------- ----------- DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --------------if--------------------- ---- <br /> ------------------------------------------------------------•�----------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------ ---------------------------------------------------'------- <br /> - - --- <br /> Final Inspection by: --- Date Z <br /> - ----- - -- <br /> SAN JOAQUIN LOCAL HEA-LT' STRICT <br /> ETH 9` 1-'68 Rev. 5M <br />