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FOR OFFICE USE: � �- <br /> APPLICATION FOR SANITATION PERMIT <br /> = ° ,16 _.__..may Permit No. <br /> --------------- .r' <br /> 1Complete�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 m'acle„in complianc with County Ordina cezNo._549_and wexistin.g;.ltules and Regulations: <br /> off' <br /> } � '_ -1 <br /> JOB ADDRI SS/L'OCAT - --- CENSUS TRACT -___--- <br /> ” 1 A <br /> Phone <br /> Owner's Name 's ------ ---- "'Q c <br /> 1 4 <br /> Address ------------- - --- _ '. itY , - --- ---- t f// cc <br /> Name ____-_---. ¢ -----.License #If - 1L_a------- Phone - KI T_ Q7._ <br /> -------- -- --- <br /> Contractor's <br /> Installation will Server {. Residence Apartment House❑Commercial:❑Trailer Court ;❑ <br /> Ni Motel ❑ Other - _ e __ <br /> Number of living units:-..�_______ Nurriber of bedrooms � -_..Garbage G.inde .-- _ ot-Size --_ Q��-�"�- -- <br /> y ___-_----_. <br /> Water Supply: Public System and name ---------_. - ----- '� h- - - _" - 9 ` - -- ---- --------Private ❑ ` <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay 'Peat&j Sandy Loam 0 --Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Materials �_Q- f yes, type ____---.---_ <br /> (Plot plan, showing size of lot, location of system in$,�"relation lo wel[s; buildings,—etc. must be placed on reverse side.} <br /> # i seepage p' p itt:d! )p_blit ewer is available within 2000 feet,) <br /> P a �r r~ <br /> PACKAGE TREATON: (No septic tank or see a e +t ermitti?d�if .0 � � � �� <br /> NEW INSTALLATION: - - CC <br /> N1ENT f ] SEPTIC TANK'f ]__t1r Si e------'-'--- - ,7 �� Liquid Depth . <br /> No. Compartments -_-_--__ - <br /> Capacity �--- Type ---�----__ ------- Material__(.. '�'' dr <br /> Distance to nearest: Well ------------------------------------ <br /> Foundation --------- Prop. Line ---.49 _.--------- <br /> LEACHING LINE [ ) No. of Lines I____..__�-------- Length of_pach line---rod- # IFO--- Total Length --- - --- -------------- <br /> Depth Filter, Material /- ----------------------- <br /> 'D' Box __�- Type Filter Materia[ _ ___ p OV------------ <br /> I / I <br /> Distance to'neare�: Well ---------- <br /> ------ Foundation Foundation ____--*9'_------__ Property, Line�_-__.-.__.:._-. <br /> P�r <br /> SEEPAGE PIT [ } DeptHl --.- - ----- Diameter J -_--___ Number -------------- ---N----- Rock Filled Yes ( No 0 <br /> ... Water Table Depth ------------------------------------ ---------- Rock Size --- <br /> Ar . <br /> Distance to nearest. Well -.--_.___------------------------------Foundation -- jm-_______ Prop. Line -. -------.------- <br /> 1 l <br /> REPAIRJADDiTION(Prev. Sanitation Permit# -•-----•..--_- ------------ ---------------- Date ----------------.--------•-•------} <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------------------- ------------------------------..---------------------------- <br /> -----! <br /> d <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- x <br /> . � <br /> ------------- - <br /> -------------- ------------------ <br /> -- ------------------------------------------------ ---- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have Jepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rule`s`cn�d"Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performanee 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 Compensationilaws of California." <br /> Signed ------------------------------ -- -- ---- -- ---------------------- Ow <br /> ner <br /> I T,itle.t& ------------------ <br /> BY ---------------- <br /> (If other th owner) <br /> FCIR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------- ------- - --------------------------------------------------- DATE `r / -� rf <br /> BUILDING PERMIT ISSUED ----------- -- ---------DATE -------------•----------------------------- <br /> --------- ----- ----------------- <br /> ADDITIONALCOMMENTS ------------------------- - ------------ -------------------------------=--------------------------- <br /> -------------- <br /> ------------------------------------------- --------------- ---------------------------------------------------------------------------------------------------- <br /> - -------------- ----- ----- <br /> ---- <br /> Final Inspection b Date ---- -1 --"----- <br /> Y. ----- �-'�t:.---�---- - - ---- -------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev, 5M. <br />