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FOR OFFICE USE: <br /> * APPLICATION FOR SANITATION PERMIT <br /> ------ - -------- --------------------------- <br /> (Complete in Triplicate) Permit No. ._.73'Z4l <br /> This Permit Expires ] Year From Date Issued <br /> Date Issued <br /> --------------------------------------------------------- <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 <br /> e in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ----/--j = -----CENSUS TRACT --•------ ------- -------- <br /> Owner's Name -----pL/ --------` - ------------------- --Phone -------I------ <br /> Address ------------------------------- ---------------------------------------------------------------------. City ------- ----------------------------------------------------------.._....... <br /> ]f <br /> Contractor's Name &.e_40_rLG------ -a,,n<----------License # ::f4 `�--�--- Phone <br /> Installation will serve: Residence K Apartment House,❑ Commercial ❑Trailer Court ',❑ \ <br /> Motel ❑ Other -------------------------------- ------ O <br /> Number of living units----------- Number of bedrooms _______Garbage Grinder ___________ Lot Size .___ _ _________________ <br /> Water Supply: Public System and name ----------------------------------------------------- ------------------------------------------------Private ®' <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan go Adobe.0 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 septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size____ -----________ Liquid Depth ------ _______ <br /> Capacity J'200 ----- Type __ ._______ Material A.07-2- No. Compartments <br /> Distance to nearest: Well ----- ` �! ~ <br /> --��----------------Foundation -�-�--------- Prop. Line ----7"�-----•---.. <br /> LEACHING LINE No. of Lines ________�--------__ Length of each line---- -----If----------- Total Length ----- 2'Qf....... <br /> -- <br /> 'D' Box -�---- Type Filter Material _______ _'--.Depth Filter Material -------- -----------____________ <br /> to nearest: Well __________ Q__�___ Foundation -----��`______ Property Line ----------------- <br /> Distance ......- <br /> CJ- <br /> SEEPAGE PIT X] Depth ___-_-_.,6--------- Diameter __ ., -____ Number _______ ______________ Rock Filled Yes No <br /> Water Table Depth 1?d Rock Size ------------------- <br /> Distance to nearest: Well _________ -----------___....Foundation ------- `.___ Prop. Line ____.- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --------------.l9--Q&__OraI---`------------------ ---------------------------------------------------. ----------------------•--. <br /> Disposal Field (Specify Requirements) -------- - --`---- -- ✓- - - '- -- '` �"�-�� <br /> ------------------------ -------------------------------------------------------- -------------- <br /> - - ----------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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- I <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 <br /> 8Y � Title --- --- <br /> - ---------- <br /> ------- -- ---------------------------------- <br /> (If other than owner) <br /> 19 1©R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _--- _ -- ------------------------- DATE _I ." l-���-----__ ----. <br /> - - -- - - ------------------------------- -- <br /> BUILDING PERMIT ISSUED ----------------------------------- ---------------------------------------------------------------------DATE -------------­­------------------------ <br /> ADDITIONAL <br /> -- ------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------- ---------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ­ <br /> --------- <br /> -- ----- ----------- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- <br /> --------------------- -------------------- / .. <br /> Final Inspection by ��- Date - --- <br /> tSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />