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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. --------- <br /> ----------------- <br /> -------------------.------------------- This Perm Expires 1 Year From'Date Issued y �+ Date Issued ------------------? <br /> Application is hereby made to the San Joaquin LocalHealthDistrict 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 .- pp :- <br /> a 4�--------- - ------CENSUS TRACT -------------------------- <br /> I n <br /> I Owner's Name --_ G W%a_A <br /> ...Phone <br /> Address rr i = ------------- CityPt - ------------- <br /> fr� p '/------------------------ <br /> :Contractor's <br /> - ---- <br /> :Contractor's Name - �'t •4--� (?•n• _ ----------------------.License # �1_. d . --_ Phone . -7�.,j r -7 <br /> 4 I <br /> Installation will serve: ResidenceKApartment House❑.Commercial :❑Traller Court ,❑ <br /> i Motel []Other i--------- <br /> / <br /> Number of living units:___- ---- Number of bedrooms,',-3____Garba9e Grinder _*Q-- Lot Size --- -------------------- <br /> Water <br /> -------------------- <br /> Water Supply: Public System and name -------------------___ _- <br /> - <br /> - ------------------ --------------------------- - ----------------------------- e, <br /> F Privat <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt-C] -_ Clay ❑,. ,Peat El— Sandy Loom Clay Loam [] <br /> a <br /> Hardpan ❑ Adobe ❑ 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 ry` 'Size_--- ._�( �------------------ Liquid Depth ...� �--._-------- <br /> E Capacity ----- Type Material_'00- No. Compartments 4; -. <br /> rDistance to nearest: Well ----- i -----------------------Foundation -----/---_----- Prop. Line _- --------------- <br /> LEACHING LINE,. No. of Li les -___- ----__ F-______ Length of each l ine_.__1QQ ----- Total Length -c ad-----__-_--- <br /> f 'D' Box )/,"__-Type Filter-Material --_Depth Filter Material -..19-------- --------.---__-_--_ <br /> Distance to nearest: Well _--- ------ Foundation _ZZ9__11----------- Property Line _15, ------------ - <br /> [ ] p ___ Number Rock Filled Yes J6 No i❑ <br /> SEEPAGE PIT Depth �.-iXGp_X� Diameter ------------- ----.------- <br />' Water Table Depth ------r�p----------------------=--------Rock Size -,�_ X i--------- <br /> Distance to nearest: Well _.377---------------------------Foundation -- --------------- Prop. Line -----_-_--__-_______ <br /> � l <br /> REPAIR/ADDITION(Prev. Sanitation Permit -----__.._-------------------------------- Date --------------- ------------- <br /> } << <br /> - � i <br /> Septic Tank (Specify Requirements) ------------------------------------- ---------------------- ------------------------ -------- ---- <br /> - ---------------- <br /> Disposal Field (Specify Requirements) --------------------------------------------- ----------------------------------------------------------------------------------- <br /> ------------1---------------------------------------- <br /> 5 <br /> {Draw existing and required addition on reverse side} i <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 Workm n's Compensation laws of California." <br /> g4 ' <br /> igned ----------------- ----- - --------------------------- Owner <br /> ------ Title ..-C/ G ByChert � ------------------------- <br /> FOR EPARTMENT USE ONLY <br /> :APPLICATION ACCEPTED BY DATE ........ -":2- - ---------- <br /> sBUILDING PERMIT ISSUED -------------I---- ------- '-------------- ------------------ ---- <br /> ---DATE <br /> ;ADDITIONAL COMMENTS ------------- ----------------------------------------------------------------------------------- <br /> --------------------------------i <br /> --------------------------- ------------------------------------------------------------- ------------------------------------------------------------------------------- <br /> is-- ----------------------------- ------ <br /> -.L ---------------- -------------------------------- -- ------------------------------------------------------------------------------------ ----- <br /> Final Inspection by: --------------- <br /> -------------------------------------------------------------. ---- 3 ;�L._----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 5 . <br /> E. H. 9 1-'68 Rev. 5M r i�, <br />