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4 FOR OFFICE USE: <br /> IN , APPLICATION FOR SANITATION PERMIT <br /> .r (Complete'n Triplicate} Permit No. _.7_�ni-----_ <br /> ---------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued -_ 3._71 <br /> a <br /> f Application is her made to,,the San'Jo \quin Local Health District for a. permit to construct and install the work herein <br /> described. This application is madae incompliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT! N -�`'------ -: CENSUS TRACT -------------------------- <br /> � �8�� <br /> Owner's Name <br /> ---------- •---------- - ----Phone <br /> Address ------- ----------- ----- -----------------------. City - <br /> Contractor's Name __-- - --- fi i, - - ,- - _ -------.License #/O_� °�- �)-�fo%6 <br /> t <br /> Phone -------------- ---------•----- <br /> Installation will serve: I Residence EjR<partment House'[] Commercial ❑Trailer Court iEl <br /> - . . <br /> ` 'Motel � -�.,,-.-... -•�. <br /> Number of living units_._ Number of bedrooms _ __ <br /> ti Garbage Grinder y Lot Size - � _________ _ <br /> Water'Supply: Public System and name -- -_ -- --- -c' / - ❑ U. <br /> �------- Private t <br /> Character of soil to a depth of 3 feet: Sand❑ r� Silt`❑]- -Clay Peat❑ Sandy Loam E] - Clay Loam.❑ <br /> HardpanE] Adobe Fill Material ./'Q--_ if Yes, type ---------------------------- <br /> (Plot <br /> ------------------ - <br /> (Plt plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septictankor seepage pit permitted if public sewer is available within 200 feet, <br /> PACKAGE TREATMENT [ 1 SEPTIC TANK - - -- — _ IN- <br /> ---------- <br /> 0 <br /> Size__. - Liquid Depth j1 - .'- <br /> i Capacity / 0-- --- TYPe [ -; . <br /> - _ Material- p- o. Compartments _02-............ . <br /> Distance to nearest: Well _______---r_"'-~_----__--Found_ati.on ------------ Prop. Line ------ k,, <br /> LEACHING LINE [ No, of Lines <br /> - --------------------- Length"of each"line_=._ -`--e'z?---�-- --- Total Len th � <br /> D' Box v._t2____ Type Filter Materialle <br /> _ /2__1&4c_-_Depth Filter Material -_. --------,----------------------- <br /> Distance to nearest: Well ________—__________ FoundationL __--_______ Property Line .__-.-___ <br /> SEEPAGE <br /> PIT Deth-- Di <br /> [] rp =--- -Diameter Z1�1 <br /> - Number-Number-------- ----------------- Rock Filled Yes o 0 <br /> Water Table Depth -----st -----------------------------------Rock Size -AIL-/Y--. -- <br /> I Distance to nearest: Well -----_______ ------------Foundation __,/L7 /-____ Prop. Line _S•______.__-___. <br /> REPAIR/ADDITION(Prev. Sanitation Permit c# -------------------------------------------- Date ----_------------_----- - _ <br /> Septic Tank (Specify,Requirement s) --------------------- <br /> - ------------------------------------------------------ <br /> -------------------------------- <br /> Disposal Field [Specify Requirements} ---------------- <br /> ------------------------------------a--------------------- --------------------------------------------------------------------------------------------- - <br /> t <br /> ------------- - --------- - -------------- - ----- --------------------------------------------------------------------------------- <br /> I <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, St e, and Rules and-Regulations of the'San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following:- <br /> AI <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 ---------------- <br /> BY -------- --- ------------- <br /> - -------- � . <br /> amu_c <br /> � = <br /> ' <br /> ------- <br /> :_ Owner <br /> - -- ---------------- ---- Title ------ <br /> (if othe an r) <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _._-�_-- -- DATE <br /> ---------- ---- - ----- <br /> --------------------------------------------------- <br /> -- ----•- ` <br /> BUILDING PERMIT ISSUED --------------T DATE t <br /> ------------------------ ------------- <br /> ITIONAL COMMENTS -------------- I---------------- ---- <br /> -------------- --------- <br /> ----------------------- <br /> -------- ------- ----------------- ------------------------------- <br /> __-----Pr-- ------ l --- - - ------------------------------------------------------------- <br /> --- -------- <br /> - -- - - - ----- <br /> Final Inspection b ► . <br /> P Y ----- ------c�- _ -p- e <br /> ate <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M �J <br />