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FOR OFFICE USE: APPLICATION FOR SANITATION PER►WIT <br /> _....-_.,_..... \ ] Permit No. _72,2--V <br /> j PM X (Complete in Triplicate) <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 made in compliance withCountyOrdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -/�- ! ------t-7-------- -`—I` - ----- -- ------------CENSUS TRACT <br /> Owner's Name a-------/ -- r------------------------------------------------------Phone _---------- <br /> Address 1 S/Li �`G -- � 21= - City . _ � �'1 ::'. <br /> Contractor's Name -. .-..6 � ( - _---------------------- - License # ��� f... Phone <br /> -_L_ _ _�---...----____ . <br /> Installation will serve: Residence ❑Wi6artment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other --- -o6_K/..,7___JL_..>---__s <br /> Number of living uhits:------------ Number of bedrooms ........._.Garbage Grinder ------------ Lot Size _.-__--__-___--_--_.._-------------_. <br /> Water Supply: Public System and name - ---01-ct_ --,-------------------------- ------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand -Silt Clay 0 Peat❑ Sandy Loam fl Clay Loam Q <br /> Hardpan ❑ Adobe ill Material '.L'C/ 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,) V <br /> PACKAGE TREATMENT [ ] SEPTIC TANK <br /> SUiz<e_�____ /, <br /> ------------ Liquid Depth !--------- <br /> Capacity <br /> __.--Ca acity ----- TYPF <br /> Material No. Compartments ...................... <br /> Q <br /> Distance to nearest: Well ....-_._.._____-....-...........Foundation ----- -- Prop. Linen.:_........ <br /> LEACHING LINE [ No. of Lines ----/------------- Length of each line ---------... Total Length ___ ��............... <br /> 'D' Box :]LIQ__ Type Filter Material PW.1%---_.Depth Filter Material ---If----- .......... <br /> Distance to nearest: Well ------------------- Foundation ---------- Property Line ..._.-_.-._. cc�� <br /> SEEPAGE PIT [ ] Depth AaK----------- Diameter ---------------- Number Rock Filled Yes ❑ No ❑ <br /> Distance to nearest: Well -------....- Rock Size ----------------------------- <br /> Water Table Depth _______ _____ __ ------T.. <br /> ----..... --------- -------------- ---- Prop. Line _----------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit # --------- -------_--_--------------- --- Date ............................------ <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) ------------------------------------ -------------------------------------------------------------.............--i........ <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------- - Owner <br /> -- ---------------------1-----T-- -- ------- - - <br /> Title _ i. //�-. ------------'--------------- <br /> (If other char wner) <br /> FOR DEPARTMENT USE ONLY 2 <br /> APPLICATION ACCEPTED BY - - - ------_-------------- DATE __ -.L4-�.------------.. <br /> BUILDING PERMIT ISSUED ---- ------------_............. ..............DATE <br /> ADDITIONALCOMMENTS ---------- -------------------------------------------------------- ---------------- -- - ----------------- -----------­------•------------------ <br /> ----------------------------------- ----------------------------- ................ -- - --- -------- -- --------------- ----------------------------------------------------- <br /> -- .. .. - <br /> -- <br /> -- - - -- <br /> - - _--_ --- -- ------ <br /> Final inspection by: - - -- Date ----------------- <br /> SAN <br /> -•- -- <br /> SAN JOAQUIN <br /> E. H. 9 1-'68 Rev. 5M C ,a / <br />