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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 'Pe' ------— <br /> _o------- - - - ," I rm i 7-3 <br /> -------------------- -------- 4 f No. .' <br /> (Complete in Triplicate) <br /> Date Issued <br /> ' 3---a----i This Permit Expires 1 Year From Date issued <br /> ------V--- <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 .../,5-t7,/------- N L----------- ----------- ------------------CENSUS TRACT -------------- ------ <br /> Owner's Name -----------IV%�41-_JAI---------------- ----------------------------------------------------------Phone <br /> = City- <br /> Address ....151�_M_ _ .4 ------------------------------------------------------------------------ -------------------------------------------------------- <br /> Contractor's Name ----------------------License # Phone <br /> Installation will serve.. Residence W Apartment HouseF] Commercial :._]F <br /> TrailerCourt E3 <br /> Motel []Other -------------------------------------------- <br /> -zr <br /> Number of bedrooms __.Garbage Grinder -WO.- Lo Size -------—,y-- -- ------------- <br /> Number of living units.---./ t iz /�V <br /> Water Supply: 134blic System and name -------------------------------------------------------------------- ------------------------------------------Private I E] <br /> Character of soil to a depth of 3 feet: SandE] Silt❑ Clay E] Peat E] Sandy Loam E] Clay,Loam E] <br /> Hardpan E] Adobe.5( Fill Material ------------ If yes,type ---------------------------- <br /> JPI'ot 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,) i <br /> PACKAGE TREATMENT SEPTIC TANK'[ I Size---------------------------- ------ -----------Lirquici Depth --------------------- <br /> Capacity -------------------- Type -------------------- Material------------ --------- No. Compartments -----------------1.... .— <br /> Distance to nearest: Well Prop. Line <br /> -----------------------------------Foundation ----------------- <br /> LEACHING LINE No. of Lines .------------------------ Length of each line----__------.----_- --- Total Length ----------------------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Z Material --------------------------------------- <br /> Distance to nearest: Well ---------------- +6undation--=_=_ --- Property Line f <br /> ---------4---------- <br /> SEEPAGE PIT Depth --------- ---------- Diameter ---------------- Number -- ----------------- Rock4,Filled Yes ❑ No 0 <br /> WaterTable Depth ------------- ------- --------------------------Rock Size ------ --------- --------------- .4%5 <br /> ID <br /> Distance to nearest: Well -----------------------------------------Foundation` <br /> ---------------------------------------Foundation` -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------___------------ Date ----------------------------------} <br /> Septic Tank (Specify Requirements) -----------------------------------------------------------------------;-----------------------------------------z.---------- ------ <br /> Disposal <br /> ---------------------------- <br /> Disposal Field (Specify Requirements) --------------- ----------- <br /> ---------------------I---------------------------------------------: <br /> -------------Q74�71'_V_ -------- ---------------------------------------------—------------- --------- <br /> I---------------------------------------------------- <br /> --------------- ---------------------------- -- ----- -------------------------------:----------------------------------------------------------- <br /> (Draw existing and required addition on:i:everse side) <br /> I hereby certify thatJ 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 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 C61ifornAid'" <br /> Signed ---------------------- Owner <br /> By ------- ------------------------- <br /> Title <br /> ---------------------- --- <br /> (If other than owner <br /> Fq)R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By ---------- --------------------------------------------------------- ------------------- DATE -------------- <br /> BUILDINGPERMIT ISSIJED _---- --- - ------ --- ---------------------------------------------------------------------------------DATE ----------- ------------------------ <br /> ADDITIONALCOMMENTS ----- ----- -------------------------------------------------------------------------- ------------------------------------------------------------- <br /> - --------- ----------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------ ------------------------------------- --- - ---- ------ - -------------------------------------------------------------------------------------------------- ----------------------- - <br /> ---------------------------------------------------------------------------------------- ---- -- <br /> ---------------- -- ---------- ----------- ----------- <br /> 1 <br /> FinalInspection by- ----- -- --- --- - - - - -------- ---------------------------------- ------------------- --------------------Date <br /> SA JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 R <br />