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FOR OFFICE USE: / � APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. ..✓ ._ e'A <br /> This Permit Expires f Year from Date Issued Date Issued /.. T.:�-7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to co sfI uEt slid'Ins ll`the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 an existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _J,`�DI_ /�-.Q..R.AN............... ............... ......................CENSUS TRACT ......... ................ <br /> f ...Phone ..... ... ... <br /> Owner's Name -i../..1..- -- ...............................................:............. ....................... <br /> Address . . . ... . . ... ... ....... ........ ...............................-...... City . . -.. . . ..... . ... ................ <br /> Contractor's Name -... 1.C./l�9lC!-...: A/}lG ................................License Ili ........................ Phone9.l 'v.12.2.•........ <br /> Installation will serve: -Residence®Apartment House Commercial ❑Troller Court C] <br /> Motel ❑Other ........................................... <br /> Number of living units------------- Number of bedrooms .a?......Garbage Grinder ..f......... Lot Size ................................ <br /> Water Supply: Public System and name -----------------------•-••---...............................--------- ---.....................................Private 0 <br /> Character of soil too depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam <br /> Hardpan ❑ Adobep Fill Material ............ If yes,type ............... ............ <br /> (Plot plan, showing size of lot, locution 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 240 feet,) <br /> PACKAGE TREATMENT ATMENT [ ] SEPTIC TANK Size...."/4 .................... Liquid Depth .�r�.� ............. <br /> Capacity la ' ...... Type/rte•` _--_..__ <br /> .. Materlal.�r.k7_ No. Compartments - "..............d <br /> ----- r <br /> Distance. to nearest: Well .�� .._ Prop. Line ........ <br /> _________________________Foundation Id-...-....... � .. <br /> LEACHING LINE No. of Lines Length of 9qch line. Total Length 9.b.. <br /> 'D' Box Type Filter Material - `••'---•_-_.Depth Filter Materia! .../,P................................ Ct <br /> Distance a nearest: Well _......1. -...... Foundation ...Ld_............... Property Line .r'p�Q <br /> ................. ') <br /> SEEPAGE PIT 04 Depth ._. ......... Diameter 31- Number .... ................ . Rock Filled Yes No C:� <br /> Water Table Depth ------/k 0--------------------------------Rock Size ................ <br /> Distance to nearest: Well .._1 rd..........................Foundation .....J d......... Prop. Line ..z�......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _--.--........--................. ------ Date ....................... <br /> Septic Tank (Specify Requirements) ---------------- <br /> DisposalField (Specify Requirements) --------•• ------------ ........................................... ---..............------....--•--.........-•-•.. ........... <br /> ---------- -- -----•--------------------------------------------------------------------------...-------- .._.................... ...................................................................... <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 San Joagvin <br /> County Ordinances, State Laws, and Rules and Regulations of the Saar Joaquin Local Health,District. Horne 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 becom blect to orkma pensation laws of California." <br /> Signed - c1( -------------------------------------------- Owner <br /> SY •----------------- Title ---------- --. . -- ------..--....----- . ...........-----...---•--.--- <br /> (If other than owner) <br /> _ FOR DEPARTMENT USE ONLY <br /> DATE A171,?. :. <br /> APPLICATION ACCEPTED BY ••.... --------- <br /> BUILDINGPERMIT ISSUED ...-....--------------_...------•--- .1_ ____:.:::::.::::------------ --------------.... DA E ....-------------------*-------------------------------------.. <br /> ADDITIONAL COMMENTS .......... -------------------------------- <br /> ----------------- ----------- ----------------....... <br /> ---------------------------*........­........ ------ --------------------------------- <br /> --- ------ <br /> ------- - •----- ------ ..........................- <br /> ................. <br /> Final Inspection by: - ----------- <br /> ------ ---•----•-------------------- -----•----- .......Date ... <br /> EH 13 2!t 1-68 11,,v• SAN JOAQUIN LOCAL HEALTH DISTRICT 8�7�, 3M <br />