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FOR OFFICE USE: <br /> APPLICATION FOR ,SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ---------------------- <br /> ----------------------------------------- <br /> --------------------------------------------------------- <br /> ---------------- <br /> �.� This Permit Expires 1 Year From Date Issued <br /> 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 /> JOB ADDRESS/LOCATION . �G -------------------------------------------------------- ----------- ----- ---------- -CENSUS TRACT -------------------- <br /> Owner's Name =-'''` -------------------------_-- ---- :--- <br /> ' --- <br /> - -- - <br /> � ` <br /> -- ------Phone ----------- <br /> Address -------- �`r` ---------------- <br /> ---------` city � r.0 <br /> hone ---------- <br /> Contractor's Name -___-. z' -.- ----------- -----744 _License # ---------Y <br /> Installation will serve: Residence ❑ Apartment House[] Commercial ❑Trailer Court <br /> Motel ❑Other _.__-92Z41-� <br /> Number of living units:------I----- Number of bedrooms __ ___Garbage Grinder -------- Lot Size ____________________________________________ <br /> Water Supply: Public System and name ------------------------------------------------------ -------------------------------------------- --------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam X 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK' SizerrFF__� 1 <br /> 1`�>-__X--J---- '� ---------- Liquid Depth -------------------------- <br /> Capacity� a_�__ Type ��� -a�_ Material___------�� No. Compartments <br /> Distance to nearest.. Well -------------5_7 ---------------Foundation ----/_(]_._----_____ Prop. Line --4�-------------- <br /> LEACHING LINE [� No, of Lines --------/-------------- Length of each line__. 0_Q.__--._____ Total Length ____ --------- <br /> 'D' <br /> _'D' Box ------------ Type Filter Material -----__S�___R----Depth Filter Material -----1-,1--//--------------------------- <br /> Distance <br /> _ _Distance to nearest: Well __61.0--- _-------- Foundation ------ -------- Property Line -----:S__ __________ <br /> I7 Depth ------A'______-- Diameter ___X l�_- Number --------/------._/___-_ Rock Filled Yes No i❑ <br /> Water Table Depth ----------------- p------------------------Rock Size J- --X---------•---- <br /> Distance to nearest: Well -------------•ate __ <br /> -----------------Foundation -------l._4------ Prop. Line -------- ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _------------------------------------------ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---- - --------------------------------------------------------------------------- ---------------------------•------------------------••--- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 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 Work <br /> m s o pensati.on laws of California." <br /> Signed ----- - - Owner <br /> BY -- <br /> ------------------------------------- r//Yl. f3` Title . -G+�r_ .Q �- <br /> (If other than ownert ) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY t<° --------------------- ------------- DATE ---- '.. --- <br /> 7"- 7� ----------- <br /> BUILDINGPERMIT ISSUED --------------------------- -----------------------------------------------------------------------------DATE -------- - --------------------------•-- <br /> ADDITIONAL COMMENTS ------------ - - ---------------------------------------------- - <br /> ----------------- --------------------- - ------------------------------------------------------------------------------------------------------------------------------ <br /> --------- y - J <br /> Final Inspection by: i--- --------------------------------------------------------------- -.Date ---- --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT A) <br /> E. H. 9 1-'68 Rev. 5M <br />