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,• FQR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. 1'7-)---`�--6 <br /> {Complete in Triplicate) <br /> ------------------------------------- <br /> ---------------------- ----------------------------------- This Permit Expires 1 Year From Date issued 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> / tea` <br /> JOB ADDRESS/LOCATION -7F .---`- !/L _L-V,' `"-� --h`'e'i.........CENSUS TRACT <br /> 44 --------------- <br /> Owner's Name -------------- -- <br /> Address ------ <br /> -tC � 91.7 <br /> = "'�r �ffw� <br /> ----------------- <br /> (� ` <br /> Contractor's Name �'�%---------------License #�=iS��------- Phone . _6_` iP • <br /> Installation will serve: Residence ❑ Apartment House,[:] Commercial :❑Trailer Court l❑ <br /> Motel ❑ Other -------;;;.7 _ <br /> Number of living units------------- Number of bedrooms _-.5------Garbage Grinder ------------ Lof Size ------- __. ___---- <br /> Water Supply: Public System and name ------------------------------------------------------------------- ------ ------Private <br /> Character of soil to a depth of 3 feet: Sand'E-] Silt❑ Clay ❑ Peat❑ Sandy Loam-E] Clay Loam/ <br /> Hardpan ❑ Adobe❑ Fill Material -----------1-yes,type ----------- ---' ---`----- <br /> (PI'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,)'';,_ b1 <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.[ ] Size=---------------------------------------------- Liquid Depth ----------'<----------.----- O <br /> Capacity -------------------- Type -------------------- Material----------- ---------- No. Compartments------------•=------ •� <br /> a Distance to, nearest: Well-----------------------------------Foundation ---------------------- Prop. Line -----------_------••-- v <br /> LEACHING LINT= { ]� No. of Liine`s"--i______:__. ---- Length of each line-;-- `_'=:_:_".f__ -- Total Length ----------------_---!------ <br /> 'D' Box -------- -•---------•-.-_-- <br /> Type Filter Material___________________Depth Filter Materia; ___._______ __ __ ._ <br /> Distance to nearest: Weil.------------------_ _.,FoundatiF n ------------------------ Property Line ------------------------ <br /> SEEPAGE PIT [ ) Depth --------------------- Diameter ----------- __ Number _---------------------------- ❑ ❑ <br /> Rock Filled Yes No <br /> _Water_7able_D.epth--------- ----- �� y Rock Siie.�,•t��. <br /> - -: <br /> Distance to`nearest: Well --1___- --------------------------------Foundation --------"---------- Prop. Line -.-------- ......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> t ) f <br /> Septic Tank.;. <br /> (Specify Requirements) ------------ - --------- -- - --------------------------­----------------- --------- <br /> Disposal Field (Specify Requirements) ------ = --------- --------------------------•----- ---- <br /> ------------------ ----------------------------------------------- G f:C Z-57 <br /> '•••r~ -------------------------------=------•-------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> (Dr6w 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 with San Joaquin <br /> County Ordinances, State Laws, ,and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- <br /> sed agents signature certifies the following: F <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 -- -- --------- - <br /> -----------------------------------. Title ...... --------- --------- <br /> ( oth an owner) <br /> FOR DEPARTMENT USE ON.Y <br /> l <br /> APPLICATION ACCEPTED BY - DATE __..- ©-- " <br /> BUI'IDING-PERMIT ISSUED ----- '_ _= =------=--- __ -. _ <br /> = _ = = =DATE _ --------- <br /> ADDITIONAL COMMENTS ---- ---------------. -----`-`=----------------------------------------------------------- <br /> ----- ----`-- - !-�_ - 1 <br /> ------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- --•----------------------- <br /> ------------- - - -- <br /> ---------------------------- -----=----------------------------------------------------------------------- <br /> --- ---- <br /> - - -------------, <br /> Final Inspection by: ----------------------------------------------- -------------------------- �--------- --Date --- f� -7 ------------ <br /> SAN JOAQUIN LOCAL TH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />