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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ............fir...7 <br /> _.. This Permit Expires 1 Year From Date Issued 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 ADDRESSAOCATION ...1.y. ..... <br /> .3.1 Com <br /> L -- ..--.-....... ... ..............CENSUS TRACT ....._....._......--- i-. <br /> Owner's Name .... _. _.x <br /> Address .' f 4f 1 ► a ,..s..... � _ ._. . <br /> Phone: _ <br /> t --... i E ... ................. <br /> i <br /> Contracto'r's Name -e � �-- -+ <br /> ' � �' ..License,# :/ '8,a c� .._ Phone r - .::'....:.:... <br /> Instalfation will serve:` Residence-❑Apart ment House❑ —Comm'ercial ❑Trailer Court ❑ <br /> i Motel {]Othe► ::-: :_ _ . . <br /> g Garb. e..Grinder, Lot-Size_ ..__,_...._-- r <br /> Number of living units; '...,; Number of.bedroo, <br /> Water Supply: Public System and name <br /> -------- vale <br /> ,._. <br /> Charq <br /> oil to a depth of 3 feet: Sand❑. silt Clay ❑ PeC:3Sandy Loam ❑ Clay Loam j= <br /> cter'af s ❑ at <br /> I Hardpan [ Adobe El Fill Material ..If yes; <br /> �— y <br /> {Plot Pign showing size,of-lot, location .o#._system..inJr.alation to..welIS-buiidirigs, !etc,:.mutt-be.placed on reverse'side{) <br /> IEW INSTALLATION: (No septic tank or seepage;pitpermitted if„public sewer is available wit}iir, 200 feet,) <br /> PACKAGE;TREATMENT, [ ]. SEPTIC TANK r� <br /> Liquid Depth00 <br /> _. E.1 <br /> Capacity” a type rr Material.�C er..- No Com actin . <br /> p eats <br /> ' k Distance to nearest: 1/Vell1 t� <br /> -._' _. Foundation [ r7. .-� Prop Line.... .�'r.. 9 <br /> LEACHING LINE No. of Line's' ;l� �.: : <br /> L"1�i Length of each {iris a ' Total: Length ° - <br /> #�'�' .. ... . 1 <br /> D'•"Box Tjiie' iltei"lVMa'#erial :':' 'I ;_ :Oc+pt♦i"Fr`iter Mciteral : ........•� , <br /> _ •_ ._�.__ .__Distance, to ner+resf,11h1e11' : G n 1.� <br /> `�- °perty f <br /> Fo'u dt�t - <br /> SEEPAGE PIT t <br /> ' Line <br /> [ j� ; Depth . ' #^• -Diameter _:::__ Numbero <br /> n :� Rock Filled Yes No <br /> Water .:Table. Dspth`, .. -Size. <br /> E•Distance ta!nearest:Well n Foundation' .lYb• E� <br /> ... <br /> 1.._ _ Prop Line <br /> r <br /> REPAIR/ADDITION(Prey. Sanita'tionPerrirlit# j <br /> .�.-...-.,.......y ..:. ... .I- ., - - <br /> !Septic Tank (Specify Requirerenfs) .. _._ y" . <br /> n' <br /> (Disposal Field (Specify Requirernents) ._:. <br /> ----- ..... ------ -----11........... <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 w�th� San Jeoquin <br /> County Ordinances; State Laws, and Rules 66d'Regulations of the'Sak Joaquin Loccil Healih MsMe't.;HOM,:a own e* or [icer- <br /> sed agents signature certifies the following:. - <br /> "l certify that in the performance of the work for which this permit is issued,.I shall not employ tiny person in such mannan <br /> as to become subject to Workman's'Compensafib laws-oft <br /> t <br /> Signed` <br /> By <br /> Owner <br /> _ Tale <br /> (If other tha ow er) ; <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �: /� Z r� F <br /> DATE ;...,.,: .../............................: <br /> BUILDING PERMIT ISSUED DATE . _. ?: :... <br /> ADDITIONAL COMMENTS . .... <br /> ----- ---- -- ---------' ; <br /> 4 <br /> Final Inspection by:,. _ j 2 ----' <br /> Date _-� <br /> SAN JOAQUIN' LOCAL 'HEALTHY DISTRICT <br /> Er H. I.3 ..24 1-'68 Rev. 5M._ c 717? a H <br />