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EOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> �/: 3 �f. Permit No. .7�......9.. <br />.. <br /> ................ <br /> (Complete in Triplicate) <br />....................... J_:. b `` ...... <br /> . Date Issued �...�6: 1 <br /> This Permit Expires it 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> s <br /> . ..__. <:.Ir . .. ............. <br /> JOB ADDRESS/LOCATION .../../'j� CENSUS TRACT ---------................. <br /> - <br /> Owner's Name ..1�'rs'l.fkyl- .....A .l,� i ,F ne .............................. <br /> .... <br /> Po <br /> Address -... .i? .�°�---- <br /> ----------•-•-••.._I....---._........ - City . '. 6 111 i ..` ._........-....� ...........�.. <br /> ,Q License #-. 1�_� • .. Phone . ' <br /> Contractor's Name � �—A? ...................... :..........• J�•'�� �.. <br /> Installation will serve: Residence Apartment House Commercial ❑Trailer Court 0 <br /> Motel ❑Other -------------- -----------•..............-- <br /> Number of living units:._f....... Number of bedrooms ._f�..r._,_Gdrbage Grinder/.V-P.. Lot Size =----••---•-•••••� <br /> Water Supply: Public System and name --------------------------------------------------------- ................................_............Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt ' Clay Peat Sandy loam 0 Clay Loam 1 <br /> .Hardpan ❑ Adobe ❑ Fill Material ......... If yes,type -----------=-- ------------• <br /> (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: INo_septic tank or seepage pit permitted if public sewer is available within 200 feet,) [�r� <br /> PACKAGE TREATMENT E ] .__SEPTIC TANK[ j Siae_:.__.•......................................... Liquid Depth .......................... 3 <br /> Capacity ................... Type .................,.- Material-------•----•--•••--•- No. Compartments ........--..........._ . <br /> Distance. to nearest: Well ....................................Foundation ...................... Prop. Line ...................... <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 E ) Depth -------------------- Diameter ................ Number ............................ Rock Filled Yes ❑ No Q <br /> • Water Table Depth ••-- .....•--:...---..Rock Size ......••........................ <br /> Distance to nearest: Well .....................................Foundation ..............-..... Prop. Line ...................... , <br /> REPAIR/ADDITION(Prev. Sanitation.1Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) ................ . --------------...........................__......._....- <br /> Disposal Field (Specify Requirements) l L�`_-_..1j�' ••--� �,/--- /'t` 'x � <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 accordance with 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, 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 /> ----- Title . ... �_......-----._....... <br /> other than owner) <br /> F DEPARTMEW USE ONLY <br /> APPLICATION ACCEPTED BY ... ....... ....................... ------ ..................... . DATE ... <br /> BUILDINGPERMIT ISSUED ........ ................................................. ...............................................DATE ........................................... <br /> ADDITIONALCOMMENTS ........................................................ ..................................................................................................... <br /> ...................................... <br /> ----- •-... .. . . ..... ---•- -------- -•-• .... .................................... <br /> Final Inspection by: ...............Date . l........... <br /> SAN JOAQUIN L L HEALTH DISTRICT <br /> F_ H.13 241-'68 Rev. 5M 7/72 3 M <br />