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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �� S a� <br /> ............ -•........................... . <br /> x Permit No. ... <br /> ....--•--.v......................................... <br /> (Complete in Triplicate) .._.... <br /> This Permit Expires ] Year From Date Issued ©ate Issued. :. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constfuct and install the work herein <br /> described. This application i de in complibri a with County Ordinance No. 549 and existing cies and Regulations: <br /> /�2.3� W IVEU(:j, r)VEp,, <br /> JOB ADDRESS/LOCATION l f �f'.._ °h! -_--- -/- _4�i��'' .. l f X0X' N*S TRACT <br /> Owner's Name ............................ .....................................Phone <br /> Address .! -... ....City �S'�, T�"1...�................ .......................... <br /> arContractor's Name 4. .....license #c V1:'v/..��.- Phone�,�ry <br /> Installation will serve: Residence❑Apartment House Commercial Otraller Ceon <br /> Motel ❑Other-046c—............*-------------- <br /> Number of living units:...I...-_ Number of bedrooms_.. .....GabageGrinder ./ .. Lot Size <br /> Water Supply: Public System and name ......................•............_........--.........:_..............................•--..................Private ❑ � <br /> Character of soil to a depth of 3 feet: Sand❑ - Silt❑ Clay ❑ Peat[P[ Sandy Loam 0 Clay Loom ❑ <br /> Hardpan❑ Adobe 0 Fill Materlal ..... If yes,type ............... ............ <br /> (Plot pian, snowing size of let, 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 208 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size........................................-...... Liquid Depth --------------- <br /> ...__------ <br /> Capacity ---- --------------- Type ................ --- Material---------------------• No. Compartments .....................� <br /> 4 <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 Materldl ........:.................................. <br /> Distance to nearest: Well ------------------------ Foundation ..........- ....... Property Line ....._......_--••- _- <br /> SEEPAGE PIT { ] Depth -------------------- Diameter ................ Number .......-................... Rock Filled Yes ❑ N <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) .......................................................... . .._..... - .. ..... <br /> Disposal Fi Id (Specify Requirements) - [3�--- lf�-�•--'! ,s `i..-. f f�--- --.1L ----.... <br /> y ._.:.---- .................................. <br /> .................. ------------..... ------------------------------------------•.................---:........_..-----------•--------------.---.••.-----------.. <br /> (Draw existing and required addition on reverse side) , <br /> I hereby certify that 1 have prepared this'application and that the work will be done In accordance' with Son Joaquin <br /> County Ordinances, State Laws, and Rules and'Regulations of the Son 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 j?�� -........--------------------------- <br /> ther than owner) <br /> _ FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY -.,-777/--R.t--a--------------------------------- -•.--.-------------------- --------------- DATE --- `T 6._.-..---- <br /> BUILDING PERMIT ISSUED ------------- -------- •-- ..._..-- .........DATE ----------•-------•-------•---- <br /> ADDITIONAL COMMENTS .......... ...• •--------•--•................ . • --------- <br /> -------------------- <br /> ----- <br /> ......-•---.---... ..........------------------•---- <br /> ---------- <br /> ------- ...... <br /> ....... <br /> - <br /> ..................... <br /> .................... <br /> -- <br /> --------- --- -•-•-• ....---- - ........ ------------------------ ---------------------------------------.-.................... <br /> .. <br /> -- ---------- ............ .......•------ ----- --------..-.. ....Final Inspection ---- ----• ---- ......-...-.... . •-Date ...6— ../ ---7-....%----•-----.. <br /> EH 13 2h 1-68 Ikv. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT Bhh 3H <br />