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_ FOR OFFICE USE _ t•',i' " . <br /> APPLICATION FOR SANITATION PERMIT <br /> 0 <br /> Permit <br /> (Complete In Triplicate) <br /> - .- -"......-_.. This Permit Expires l Year Frear Date Issued Date Issued S.ct37:.1.Q <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: 3w <br /> JOB ADDRESS/LOCATION ,3.SA. ...EI!h ✓elf " (..�? _ CENSUS TRACT ... . .... `L <br /> Owner's Name .....:.:. / " - <br /> / �.i�P.�- .. .._ .Phone ! . ': Z. 4. <br /> Address ._.. .��,tyi� lffa,e,Z/ S/,6,f. <br /> Contractor's Name ./!CE-r _....._. _.:. .. ff-f/ ........City . ......... . ... . . <br /> [ <br /> ..- .License# ..:..: ...: Phone ......... ........—i........ <br /> Installation will serve: Residence M Apartment House Commercial ❑Trailer Court Q <br /> hi y <br /> Motel ❑Other ._ ..._ ... .. .. ... ... . ..... <br /> Number of living units: ........ Number of bedrooms ....2,--.Gorbage Grinder AVO.. Lot Size - <br /> .......... ::. <br /> r Water Supoly: Public System and name ........................................................ <br /> ......................................................Private❑ <br /> Character of soil to a depth of 3 feet: Sand f? Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 4 <br /> a: Nordpon❑ Adobe ❑ Fill Material .... _..... If yes,type........................... ?� ,- <br /> (Plot plan, showing size oflot, location of system in relation to wells, buildings, etc. must be placed on reverse side t . <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK[] Size......................... ................ ..... Liquid Depth ..................... <br /> j <br /> Capacity........... ........ Type .................... Material............._....... No. Compartments 1 <br /> Distance to nearest: Well .-.._..............................Foundation ...................... Prop. Line_.-.---......-..-.-.. <br /> LEACHING LINE ( j No. of Lines -_,,................... Length of each line............................ Total Length ...........-................ <br /> 'D' Box ....... —. Type Filter Material ....................Depth Filter Material ----- <br /> ..........................._........... <br /> - •--- Distance to nearest: Well .._:...... Foundation ........................ Property Line - " <br /> SEEPAGE PIT [ J 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 Permit/y(F ..... ..... ................ ..../........... Date .............-......-.........-...) <br /> Septic Tank (Specify Requirements) ....JC.C.F�rL�.C'.....C-t'_fLTi.�....--....( ........4vX!1/1....._l. d.... ...-....-. <br /> ..,J ................................................_..._....._ ................................... <br /> ................................_............................................ <br /> ......................................... ............ ........... . ......................................._..............................................."................................ <br /> ..:...--.., yjT <br /> (Draw existing and required addition on reverse side) "Q <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San :,,aqui, -$ , <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health Dis4rict. Homn owner or (leen- <br /> sed ogenls 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." 1[ <br /> Signed ... ........:::- %.< :.. ........................ Owner tE <br /> By....... -.........................__...................--........................................ Title ........_ ..... ................................. <br /> .....-.-..........-._ <br /> (if other than owner) <br /> FOR D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY........ ..... ......-.. . . _ ._-....-..._.....-..-......--...-...-.-..._...---........ DATE....Sts.�.'�,0.. .. <br /> BUILDINGPERMIT ISSUED.............................._..-...----:......-.--........... ....... *._..-..-.......-.-'---`---DATE.. .........................-...._...._.. <br /> ADDITIONALCOMMENTS.........................----......-...-..-----._..._.--.....-......-....-.....-.......-..--.............-..-.......-...---.-...-.---....-........_.-... <br /> .....................'-'---..--..-....-...........-...---.-.--...—.-..---.--.-....-......-.--....-...--....-................--.-...-......-............._.........----..........-.....-..-.....-......-- <br /> ................................. :-...--..--.-.............-.......-........-..................-...........-.-.............................................................. <br /> ..................... <br /> Final <br /> Inspect-_........... ....... .. .._--.......-...-..--.........-............-.-_..---.-.-.-.-..............---"-----....-15--i-...--..�- <br /> Finallnspectionby: .-.._ - ..................._--..--_......_...........-......_.._...-.............Date..-.. ..:,�-7d.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E.H. 9 1-'68 Rev. 5M <br />