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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. _7_3-131---- <br /> (Complete in Triplicate) 1 <br /> - -------------------- ------------------ = / <br /> Date Issued _________ <br /> ----------_------------------- - This Permit Expires 1 Year From Date Issued <br /> Application is hereby made tc the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and exis ing Rules and Regulations: a <br /> rt,-A)0 U jir cLz. � �. ��� <br /> ��tt 11 CENSUS TRACT .-%3?-----•--------- <br /> `JOB ADDRESS/LOCATION '__ '` G---- " r '_ <br /> Owner's Named L /1�---------- .f1a1U1-----�--------------------------------- ------{--------------Phone ----------------------------------•- <br /> Address -------- #'t_ Q-2C � �� ,���4� 11� ------------------- -- - City ------------------------------------------- d4d --------•-- <br /> i <br /> Contractor's Name .--- ----License # -----°--:------- <br /> Installation will serve: Residence Apartment House❑ Commercial:❑Trailer Court ❑ <br /> Mote!'❑.�ther --------------------------------------------- <br /> Number of living units:---t------ Number of be&oms —03' ----Garbage Grinder - __ _ Lot Size _�'` -------------•----- <br /> Water Supply: Public System and name ----------- -�"` f -----------------------------------------------------Private <br /> ' : Ati <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt El Clay ❑ Peat❑ Sandy Loam Clay Loam :❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type -------_------------------- <br /> (Plot 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 <br /> p seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![ ] Size------------------------------------------------ Liquid Depth -------------------- ----\x <br /> Capacity -----' - Type. -------------------- Material-------------------- No. Compartments .----------------•---- <br /> Distance to nearest: Well ---------------------------Foundation ---------------------- Prop. Line -------------------....�._.._- <br /> t L <br /> LEACHING LINE [ ] No. of Lines;------------------------ --------------------line <br /> - ----- Total Length ------.---_•-----------•-•-� <br /> D' Box ----___ T e Filter Mate al of each line h Filter Material ____________________ ...........1 <br /> Distance to nearest: Well -----y------------------ Foundation ------------------------ Property Line. ------------------------i <br /> ` - Rock Filled Yes No i❑1 <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ------- -------- N{umber --------------------------- ❑ <br /> l <br /> Water Table Depth ------------------------------------------------Rock Size ------------------ ---------- <br /> t <br /> Distance to nearest: Well ----___-------------------------- -----Foundation --------- --------- Prop. Line _.___._._..-___....fir i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> -__-_--_--_----.---------_-------Se tic Tank (Specify Requirements)`-------- `-------------- --------------------------------------------- <br /> Disposal Field (Specify Requirements)---.-.---a---------------------_ ---,l ---•--=------� �' ----- i <br /> y– -------------------------------------------- - <br /> ----------------------------------------------------- -- ---- ----- ------------- <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�pc�ordance with San Joaquin <br /> i. <br /> County Ordinances, State Laws, and Rules dnd Regulation's of the San Joaquin Local Health Distriit:Horine 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 /> --------------------------------------------------- <br /> (If other than owner), <br /> f FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED Y --------------------------------------- DATE -- - ---��----------------•. <br /> - - ---- - ----=---------------- -- <br /> BUILDINGPERMIT ISSUED ------ -------------------- - ----- - -------------------------------------DATE ---------------- ----------------•-------- <br /> ADDITIONALCOMMENTS - -------------------- -------------------- ------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------- ------------------------------------------------- <br /> ------------------ ------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- <br /> ------------------------------------ :--- -------z----------- ----------------------------------------------------------------------------- --------------------------------------------------- <br /> -- -- --------- ---- ------------------------------------------------------------- -------- ^~, <br /> -- ------ - - <br /> _ -- -------------=------- <br /> Final Inspection bY` Date _ `'X <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />