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.11 <br /> FOR OFFICE USE:" <br /> APPLICATION FOR SANITATION PERMIT X73 <br /> F....................................................... Permit No. 7y! <br /> (Complete in Triplicate) <br /> .......................................................... <br /> Date issued <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 #n compliance CcWty Or��ce,�fo, 549 and existing Rules and Regulations: <br /> . /tee <br /> JOB ADDRESS/LOCATION .........................................CENSUS WTRACT ...... <br /> 6wner's Name �� T ::1 1 C ...... -4PM�✓4lAlOr. ..... :......... Phone�,�...� ............ <br /> Address ­� ........... ........................................................................... City .............. --- .................... <br /> Contractor's Name ,1� .. f' �lC..._5• ------•..............License #� ...:.. Phcne .Sa. .��... <br /> Installation will serve: Residence ❑Apartment House 0 Commercial:(Trailer Court 0 <br /> Motel ❑Other <br /> Number of.living':units: .... Number of bedrooms .......Garbage Grinder.".._. Lot Size ......... <br /> k <br /> Water Supply: Public System and name ................-----...............................-........................................•........... _.Private <br /> Character of soil to a depth of 3 feet: Sand E] -Silt❑ Clay ❑ ' Pea#.I] Sandy loam 0 Clay Loam 0 <br /> Hardpan Q Adobe-W Fill Material ............ If yes,type ...............------------ <br /> (Plot plan, showing size of lot, location of system inrelationto 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 204 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 14 Size. r .`.....................• Liquid Depth _IP"r................ <br /> Capacity .......... Typeff�xv___-_ Materialalal No. Compartments X............:.... <br /> Distanceto nearest: Well .AiV4P_ ..........................Foundation ./0......... Prop. line ,ir................. <br /> LEACHING LINE•.. No. of Eines _._ ......:......... Length of each line--- Total Length �� ------ ........... <br /> 'D' Box &, ... Type'Filter Material ROC&.......Depth Filter Material .....1A...............I................. <br /> Distance to nearest: Well ./0.. ............. Foundation -�iT._..._.-..__.... Property Line .....______......., <br /> SEEPAGE PIT [ j Depth .......:.:.......... Diameter ................ Number ...__..................... Rock Filled Yes Q No [ <br /> Water Table Depth ...............Rock Size .................... <br /> Distance-to nearest: Well ........................................Foundation ................ Prop. line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation-Permit# ....................•....................... Date ..................................I <br /> SepticTank (Specify Requirements) ...... ...........................................................................--......................___.......................... <br /> ' Disposal Field (Specify Requirements)` <br /> .......................•.............................. . ----•••---............----•-----..........._...---•----•---..............-----...------...........-•-•-•-----•--•---......••.•_..... <br /> ...................................................,•........-••---........._._._..........__.._....................._..._.....---..............---._........._._..............- 1 <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 w#th 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, 1 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 .. . <br /> (If other th own <br /> F DEPARTME T USE ONLY <br /> 42 <br /> APPLICATION ACCEPTED BY ... �' <br /> DATE .... ............7.. -7. .. <br /> BUILDINGPERMIT ISSUED .... ..................................................... ..............:........_ .....................DATE ........................................... <br /> ADDITIONALCOMMENTS ...........I............................................ ............................... --..........-------•--•-•--.........:.------.._.........------.. <br /> .................................... <br /> ......... ,.... ........ 11....................................................................... <br /> ------ <br /> ......................... .. ... . .... ...... ...--• •-- -- ....................-----..._..........•-•-..-------••-•-- {� <br /> Final Inspection by: ...........Date _._ -- `-- .•-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ) <br /> 24 j 3M <br /> 13 <br /> E. H. 1-'613 Rev.'SM 7 72 <br />