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FOIZ'bFFICE-USE: <br /> APPLICATION FOR-SANITATION PERMIT <br /> ----------------------------------------------- <br /> Permit No. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date I ssued Date issued <br /> ------------------------------------- <br /> 7--------------- <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 -.-' j/--7-4 -/-------/ _6,1_4__yv----------------------------------------------CENSUS TRACT ----------- .............. <br /> Owner's Name .-J.-7 1.........R-u-s-1-p-t-1-----------------------------------------------------I-------------------Phone------------------------------------- <br /> Address ---P-76-j------r _bz_dy,�---------------------------------------------- city -/�/ZAOV -- ----------------------------------------------------- <br /> Contractor's Name ---- ,C_ _ .__ ---------------______________License # Phone <br /> Installation will serve. Residence C)g Apartment-House-E] Commercial Trailer Court <br /> Motel ❑Other 167P/Oij---- 4f------ <br /> Number of living units:____.__.___ Number of bedrooms _1----Garbage Grinder ------------ Lot Size -------------- <br /> i I - _41aarvf_- I <br /> Water Supply, Public System and name ---------------------------_------•------------------------------------- ---------------------------------------Private <br /> Character of soil to a depth of 3 feet: Fanci76 Silt Clay E) Peat E] Sandy Loam X Clay Loam-0 <br /> Hardpan E] Adobe ,E] Fill Material --- ------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system 'in"r;la­tion ito m;e[IZ 66ildings, 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,) <br /> _L_ _ ------------ <br /> PACKAGE TREATMENT SEPTIC TANK f Size-----/P�X----6 /--0;rT': Liquid Depth"__,yl <br /> Capacity ----- Type No. Compartments __1?----------- <br /> ----------------------- -------------- <br /> Distance to nearest, Well ------- _________________Foundation ....4-6-1------- Prop, Line <br /> C.-I <br /> LEACHING LINE No. of Lines -------------------- --- Length of each line----- ----- --------- ------ Total Length ----------------------------- <br /> -D' Box ------ Type Filter Material ____________________Depth Filter Material _.----- ------------------------------- ------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ <br /> SEEPAGE PIT Depth -------------------- Diameter ---------------- Number ------ -- --------------­-Rock-Filled , Yes E] No C] <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- N <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------- ---------------------------------------------------------------_1----------------------------i--------------- ------------ <br /> 0 <br /> Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- <br /> ----------------t-----------------------------------------------------------------------------------------------------------------------------------:-------------------------------------------------------- <br /> ---------------------------I---------I--------------------------------------------- ------ ---------------------------------------------------------------------------------------7------------------------- <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 with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signr tae 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 <br /> --- subi...e <br /> ct-t-o- <br /> Work' n's,.Co_ompen-sa—A tio—n l <br /> ayI s of California." <br /> Signed- -0- -- -- I ----- --- ---- Ow <br /> ner <br /> 1BY ------ Title ---- <br /> ------ ---------------------------------------------------------- - <br /> (if other than owner) - <br /> FOR DEPARTMENT flSE 9NA <br /> j <br /> -------- -- - - --V_ DATE -21 <br /> APPLICATION ACCEPTED By----------------------------------------- DATE <br /> ------------------------------ <br /> BUILDING PERMIT ISSUED -------- - ------------------- -- --------- --------------------- ..... ....... ..DATE -------------- --------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------- --- ---------------------------------- -------------------------------------------- -------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------ <br /> --------- <br /> , . ,:�_77 <br /> Final Inspection by: ------------------------------------------------------------------- Date -------- ----------------------- <br /> ---------------------- <br /> SAN JOAQUIN LOCAL HEALTH DIe <br /> E. H. 9 1-'68 Rev. 5M <br />