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FOR OFFICE USE: <br /> F APPLICATION FOR SANITATION PERMIT <br /> - -- ---- -- - - - Permit No. _4W:,��7�7- <br /> (Complete in Triplicate) <br /> ------------ ----------- ------------------------------- <br /> Date Issued F-�.�_`-6- <br /> ' 4 { ` This Permit Expires 1 Year From 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 /> i < k t!--------- -- <br /> JOB ADDRESS/LOCATION .1_l-_t - --- F ---- - /` CENSUS TRACT -------------------------- <br /> Owner,'s Name ' G --- ---------------------- Phone �a' �F'r� <br /> Addre's --- ��' 's� city �'"� <br /> # t ---.License # --------- ------ Phone Y6�6- rte----- ---7- <br /> Contractor's Name } --------- ----- -c-Q � ---: <br /> installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court :❑ <br /> .__... Motel ❑Other ------------ -------------------------- <br /> Number of living units:....)----- Number of bedroomsl --Garbage GrinderoVP____ Lot Size ___________________________________._._-- <br /> t <br /> Water Supply: Public System and name --------------- -----� Private <br /> Character of soil to a depth of 3 feet: Sand.' .,. Silt..❑ Clay Q. .Peat E] �a,~�ndy Loam ❑ Clay Loam ❑ <br /> Hardpan F-1Adobe ❑ mill Materi l ---------- _ If yes,type ---------------------------- <br /> (Piot on, showing size of lot--io ation of system in relci ion : o,�wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION 1 �Nb septic. ank,or(seepage pit permitted�if }� li'c�s weris available within 240 feet,} <br /> ,k fa of <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![ ] Size_____`= �_a_....____ -------- --- Liquid Depth -_ W______________ <br /> Capacity :._ Typee __70� Material . _._ No. Compartments ____ ........ <br /> /C� <br /> Distance to nearest: Well _____._�00_________._______foundation -----��?____------- <br /> Prop. Line __________ ___�_______ <br /> LEACHING LINE [ ] No. of L nes ------�----------_ Length of each tline_/oQ"-_�___ Q -_ Total Length ___Z6-jO..�-._--- <br /> 'D' Box�l�_ Type Fi[ter-Material.�g ------ Filter Materia! ----------/�- .-.------- <br /> ' Distance to nearest! __=--r'- '-#"� - I ----- -- -------- Property ----•-•--- <br /> ____.--- foundation ��- Pro er Line _. ___ . <br /> SEEPAGE PIT [ ] Depth __________________I diameter ---------------- Number ______-----------__________ Rock Filled Yes ❑ No <br /> Water Table Depth ---- -------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well --------------------------- --]- - Fundation --.---------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------------------- Date _-__________-I__-_______________-_) <br /> Septic Tank (Specify Requirements) .-------I ----------------------------------------------------------- ------------------------------------------------------------ <br /> Disposal Field (Specify Requirements) -1------------------ ------------------------------------------------- -------------------- -----------------------•--------------- <br /> ------ ----------- ------------------------------------ -------------------------------------------------------- -------------------------------------: ------------------------ <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 IOrdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen. <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, I sholl not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------- ---------------- O to Owner C� �, �-- <br /> B R �!Titl`e .........'—E:Id ------ ------- ------------------------------- <br /> Y ----- . <br /> (Ifo than owner) l <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . DATE -0'--I_g`/X------------- <br /> BUILDING PERMIT ISSUED ---- ------------------ --------------------- - DATE <br /> ADDITIONALCOMMENTS ------------------------------------------------------------- ------------------------------------------------------------------------------------------------ <br /> ----------------------------------------------------------------------------------------------------- ----------------------- ---------------------------------------------------------------------------- <br /> -- -- --------------------------------- --------- ------------------------------------------- ---------------- ----------------------------- ------------------------r---- ------------------------ <br /> %.�------------------- ---------- -- -- - - --------------------------------------- ------------------------- ---- --------------------- <br /> Final Inspection by: _ ------ ---- ----- --------- - -----Date - `'.-_ . - - ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M {0\Jep-� <br />