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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br />_....._.... 7' �.8 S� <br /> Permit No. ..._.T...` _. <br />_............................. ..................I....._. <br /> (Complete in Triplicate) ""'"" <br /> This Permit Expires 1 Year From Date Issued Date Issued 16/7/Z -.. <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 wi County Ordinance No, 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATI N .._./ '' .?.Le ._.e�.._.._ s. ... � <br /> CT .......:.................. <br /> TRA <br /> Owner's Name ....... --.-... ._.....Ph ne .1'. ... <br /> Address ..._.._ . ��. f' .f. z.. .. �x�, _. . City -. - =-F .................................... <br /> Contractor's Name ... ✓!Gs ,J�..., ._�, .License # f. _ Phone' <br /> hone ..�� -�A..: . <br /> Installation will serve. Residence jXApartment House Commercial []Trailer Court 0 <br /> Motel ❑Other ................................ <br /> � p <br /> Number of living units:...... __._ Number of bedrooms ___Y ..Garba a Grinder .._. _.... Lot Size _..,C�_Q_'_._� ­�._____ .____. <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 Loom 0 <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 penifted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK T ............................................. Liquid Depth .......................... <br /> Capacity .................... Type ... ......... Material----_---------------- No. Compartments ............ <br /> a0 <br /> Distance to nearest: Well ................. ... ..............Foundation ...................... Prop. Line .................. <br /> LEACHING LINE 5 No. of Lines ...___.__ __ . <br /> �.......... Length of each line.------ ------ Total Length ............ <br /> 1 01'D' Box _` Type Filter Material Depth Filter Material ...............:...:._. <br /> Distance to nearest: Well .�~Q`.............. Foundation ..../4! r_. Property Line S'.� <br /> ! <br /> SEEPAGE PIT � Depth otf ..._------- Diameter Number -------l................. Rock Filled Yes 4 No (] <br /> Water Table Depth -------- ......................:........Rock Size _..-_sa .`•_ .............. F <br /> Distance to nearest: Well -_ Aa...C1.......................Foundation ..... . ... Prop. Line ....' ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit#' --•----•------•............................. Date ------. ........................ <br /> Pt (Specify. eqe ► - .....--- <br /> �I t/}1� <br /> : . . <br /> Disposal Field (Specify Requirements) <br /> , ..... .... ... .. .... --- . ........................................................- ....................... <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 Owner F <br /> BY --••------ ........... .. .... `.:-------.- Title ....---- ---- •-•.._ <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ................C.,/_.�..... ---------•----------------------------..._...__......--.--••--...., DATE .....c�i. ..,4 ..,Zy�................. <br /> BUILDINGPERMIT ISSUED ....------•----------------------•------••--•-------...._......--•----•-------------------- ------------..DATE ........................................... <br /> ADDITIONALCOMMENTS .................................................•..................................................................................................... <br /> . ----•--•-••-. ---•••--•--••-----••----••-----•................................••----............................. <br /> - -- -- ---- <br /> Final Inspection by: ..........Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.3-3 241-'GB Rev. 5M 7/72 3 14 k <br />