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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT v <br /> (Complete in Triplicate) Permit No. . `� 3/ <br /> -------------------------------------______.------- This Permit Expires ] Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for l 3permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance Na. 549 and existing Rules and Regulations: I <br /> JOB ADDRESS/LOCATI '-- p�-4s --1`Er�'; - - -- - -.-_-CENSUS TRACT -------------- ---------- <br /> - <br /> Name --------- `---- ---- -- ---_ r - _S✓17_ <br /> --- --- -- - ---y- �------- -- --- ----- •-------------------Phone -- - ---- -• - <br /> Address -------------------------------•----- <br /> �d`�' oL.r�t . city - /` <br /> Contractor's Name ----- 'rQ"7 .cs---------------License #�ll f Phoneb.(D__ L?�. <br /> Installation will serve - "­Residence- en Apartmt-House <br /> Mfj-Commercial-:(]Trailer Court ;0❑ <br /> r otel ❑Other == =-_----,--- -•--------------------- <br /> Number of Iiiving units:....____ Number of bedrooms _ ----- Grinder _.� ___ Lof.Size C�t ---------------- <br /> i t <br /> Water Supply: Public System,and:,name-_". ---c"_"='=--'.�=------------------------!?------------------ --------------------Private <br /> Character of soil to a depth of Ved`t,:a Sand'(] Silt❑ Gay .❑ Peat❑ Sandy Loam <br /> -❑ Clay Loam,0 <br /> Hardpan ❑ Adobex Fill Material ------------- 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 <br /> x w (No septic tank�or-seepage pit permitted if publfc sewer is available within 200 fed#,) 1 <br /> PACKAGE fREATMENTt f ] SEPTIC TANK'[ ] Size--------------_------------------------------ _ Liquid Depth ___Y ___---_-,_._.. <br /> I Capan.ty -------------------- Type ---------------------� Material---------------------- No. Compartments ------=--------------- \� <br /> ~` r �l1 <br /> ! Distance td nearest: Well .I ` _:a___________Foundation _____.__:___ : ` "' <br /> I ... -�- T ------.I- Prof. dine :__..._ <br /> LEACHING LINE [ J No. of ­j-------------------- Length of'ea h line---------------------------- Total ,Length .-_--- -------------- <br /> D' Box ---------- Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distanceeto°nearest: Well-.-_______'---------- Faundatiori---- l ----- <br /> f � [ 1 .:.�- Property Line-�-��`-.--- "..+ <br /> r � � <br /> SEEPAGE PIT e A' Depth•,.a--------± -------•Diameter-------— - Number -------------------_______ Rock Filled Yes ❑ No i❑ <br /> -Wa#er.Table Depth ------------------------------------------------Rock'Size <br /> '..Difit'ance to nedrbst. Well. _-_-. ------ Foundation ___.__!____'`':�__)_ ;Prop. Line -------- ........ <br /> REPAIR ADDITION Prev. Sanitation Permit # .:_._�----------------.---------- _______________ _ -_---_�y1 ,, <br /> . 4eptic Tank�(Specify Requirements) ------------------- ----------------------f- - = *., , <br /> .�Disposal_Field (Specify Requirements)—­ <br /> _/= - <br /> ----------------------- — - <br /> -'°"_ -- --------- - <br /> ~--3 -- - �� .-•,�.:, ----------------------------------------------------------------------- <br /> ------------------ - ------------------ ---- -----_ _!�,--------------- --------------------------------- --------------------------------- <br /> (Draw <br /> ----- - - ------------------•--------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that"I'have preparedilii"upplication'cnd-thpt-tke wor-k will-be done irf-atiordance'with SonJJoaquin <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+ssued, I shall not employ any person in such manner, <br /> as to become subject to Workman's Compensation laws of California. <br /> Signed ---- ----"erthan <br /> ----- ----- Ownerl, <br /> P --------------- <br /> 9 <br /> By --------------- Title -------- ----- ----- -- <br /> - - ----------------------------------------- <br /> er) <br /> FOR DEPARTMENT USE ONLY <br /> DATE o}�`'-~l '� <br /> APPLICATION ACCEPTED BY = ------------ <br /> BUILDING PERMIT ISSUED - -- - ---- -------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --------------------------------------------- i <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------- ----------------------------- <br /> ------------------ --- ----------------------------------------------------------------------------------------- ----- -- <br /> FinalInspection by- ----------- -------------------------------------------------------------------------------------- ----.Date --. -0 -- --- -- -------- <br /> SAN JOAQUIN LOCAL H TA-D1 RICT--- <br /> E. <br /> ' <br /> H. 9 1-'68 Rev. 5M <br />