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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------- -------------------- <br /> " Permit No. <br /> (Completein Triplicate) <br /> ------------------------ -------------------------------- <br /> ------ <br /> ---------------------------- <br /> Date Issued S__/_1 <br /> ___________------------------------------__._____________ This Permit Expires 1 Year From date Issued t <br /> Application is hereby made tc 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 Ordinanc No. 349 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------/�0-�-� �,�------------------CENSUS TRACT -------------------------- <br /> Owner.s Name -----72V) �f'� ------- -- -- ----- ----- --------------------------- ----- .Phone ��__ "s�l --- ---------- <br /> Address /7 Q//12 City �-� e f-- -- -- ' <br /> Contractor's Name --a/ �___(,� - - ___ _____________-________-License #aVF°,9.2Z__.- Phone <br /> I <br /> Installation will serve: Residence ]A rtment House-[] Commercial :❑Trailer Court ;❑ I <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:_:/ ___ Number of bedrooms _3-----Garbage Grinder -----------. Lot Size% __X? ______________ <br /> Water Supply: Public System and name -------------------------------•---------------------------------------•---------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand,❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Gay Loam:❑ <br /> Hardpan ❑ Adobef; 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.) ai <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size___ ,1--_----__r -rr' --- ----- Liquid Depth -----Af---.__�;_____ <br /> Capacity -- Types ``` -- Material .,��y.— No. Compartments - ------------ 6 <br /> 1� ' <br /> Distance to nearest: Well -----PZ2___ ------------Ie--- __---___ Prop. Line ---C__............. 10 <br /> LEACHING LINE [ ] No. of Lines ----P2 Length of each iip�e----15;,o-________________ Total Length :___, 1J'-_-________ <br /> 'D' Box _ ,.__ Type Filter Material�� c -,_Depth Filter Material ,l� <br /> - ----------- ---•------- �. <br /> Distance to nearest: Well _-_ 7J___-______ Foundation d r-._________ Property Line ----Sr_-____..__-___ <br /> SEEPAGE PIT [ ] Depth _ Diameter C_93_-------- Number -------J�" ------------- Rock Filled Yes No [I <br /> Water Table Depth ----------R ?--------------------------------Rock Size --- <br /> Distance <br /> -Distance to nearest: Well --I-------- -------- - -•--Foundation __a9­Q---`-------- Prop. Line ---- - --- <br /> .--_ <br /> --------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------- Date ---------------------------------- <br /> -------------- <br /> -----------------------------_ -_) <br /> Septic Tank (Specify Requirements] ----- fl <br /> DisposalField (Specify Requirements) ---------------------------•--------------------------------------------------------------------------------------------------------- <br /> --------------- f <br /> ------------------------------------------------------=------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse sidel F <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." } <br /> Signed ----------------------- Owner kl <br /> _. ��c.4. ---------------------- Title -------- --------- ----------------------------------------------------- <br /> (If other th owner] <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ________j___._�_ S'2 7 <br /> - ----�---- " -- --- --- DATE -.-- - <br /> - --------------------------- <br /> BUILDING PERMIT ISSUED --------------=----------------------------------- --------------- ---- <br /> -----------------=--------------DATE --------------------------------"---------- <br /> -- <br /> ADDITIONALCOMMENTS i----------- - -------------------------------------------------•--"--------------------------• ------•-------------------- <br /> _________________________ _______-___-_._-_-___-__________.___--__-____________.__._-___."_ .-_.___„_-_-______-C______.._---__. <br /> ___________________________________________ ______ _ _____ _ <br /> ._ _ _ _ _ ______________"_ _ ______ __ __ _ _ <br /> Final Inspection by: -------- - --- --- ----------- -------- -- ----------------.Date f '" I <br /> - - - - ------ - <br /> ---- - ---------- ---- ----=------- <br /> SA JOAQUI LOCAL HEALTH DISTRICT <br /> 9 1-'68 Rev. 5M �� <br />