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M 0 <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------- --------------- Permit No: - -- ------ <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 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 /> JOB ADDRESS/LOCATION <br /> ---------��000.__X�s�N__R-el--- 7 _ .11_-..--___-__--_.CENSUS TRACT .......................... <br /> Owner's Name ------- ---��dy---------�A-P--------------------------------------------------------- -------Phone f14r7_7 R 5'-.----- <br /> Address ----sAa_AcAtOW_f�t_VICY Ctv6------------- City --TY*4`-�--------------- --- - --------------------------------- <br /> IContractor's Name _ 't_ H /S_o!_ly License #/t4-_4r$4 Phone "Y-----�l <br /> Installation will serve: Residence (X Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units:_._1______ Number of bedrooms ----I------Garbage Grinder --------- Lot Size ___ ----------- ........ <br /> Water Supply: Public System and name ----------_7.-_X.-&-C_,--------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ,N Clay Loam ❑ �! <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type -__________________________ � V <br /> 'o- <br /> 8 <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------------------------------------.------- Liquid Depth _____-_-----_-__-___-----r- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------------_-----_ <br /> Distance to nearest: Well -._-______________________________Foundation ---------------------- Prop. Line ___ .................. <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ,_______________--..-_--- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------_------........................ <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ________-.-__-_-------_ <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number __________ ----------------- Rock Filled Yes ❑ No C <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------•------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ----------------------------..-------------------•------- <br /> Fi_L Tc►Y d �s�X-. /4e�gl'f 7i onr `' "X%f7%Ae <br /> Disposal Field (Specify Requirements) ___________ <br /> �r -S_TCM--------------------------------------------------------------------------------------------------------------------------------------------------------------------------•- <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -14 rT1{ ° X--'F---SoA/" ------ Owner <br /> By ------ - Title ----------------------------------------------------------------------- <br /> ( owner) <br /> FOR EPARTMENT LJSE ONLY <br /> APPLICATION ACCEPTED BY ---- - --- --- ------------ DATE ------ -. /-7 ----------- <br /> BUILDING PERMIT ISSUED ._.______.-___ _________________DATE -.---._____---_ <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------- ------------------------------------------------------------ ------------------------------------------------- ----------------------------------------- <br /> ------------------------------------------------------- -- --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - -- - ---- ----------- <br /> rr <br /> Final Inspection by: --- ---- ------ �-------------------------- -------------------Date --- f '- Z---------------------------- ------- -------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />