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FOc' OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> P <br /> `. fpd I <br /> .' <br /> Permit No: -7 = <br /> (Complete in Triplicate) <br /> ----------- --------- .. £ t� <br /> Date Issued --�._... <br /> -------------------------------------------------_-- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Sain Joaquin Local,Health District for a permit to construct and- install the work herein <br /> described. This application is made in corriDliance with County Ordinance No.,�,549 and existing Rules"-ancL Regulations: <br /> c ' G.�, f' CRUS T �i"L���; c <br /> JOB ADDRESS/L ION �B-- ------ w_ __ �-�..V �.. E S R C7 <br /> yy <br /> = "�'---- ------- Phone <br /> Owner's Name --- ----- ---- --------------------- ----- --�----------- - - -------------------- <br /> Address <br /> - ------ ---••---- <br /> Address -------- . City ------ :'::--------- - <br /> LZI <br /> w` ' -----------.License # CTI Phone _ .1. <br /> Contractor's Name ___ - �_ __________ __��nt <br /> � ❑ ❑ <br /> Installation will serve: Resi ence House Commercial : Trailer_Court <br /> Motel ❑Other y <br /> Number of living units:__:------ Number of bedrooms ___ ___Garbage Grind _- ------ Lot Size-� --/-_.�_.��______________ <br /> Water Supply: Public System and name ------ ---------------=----------•---------------------------- ----------------- -------- -------------Private <br /> 5 <br /> Character of soil to a depth of 3 feet: ' Sand:'❑ : Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam. <br /> E <br /> Hardpan ❑ Adobe' ill Materia)eV _-_ If yes;type__ _________________________L ill _ <br /> t..;. <br /> (Plot plan, showing size of lof, 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;2200 feet,) !" <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC I Size_______ __ ___ `_4 - - Liquid Depth _._/___� ___,..___ <br /> : -t= �f <br /> capacity Type Type _ - MaterialNo. Compartments �---------------- <br /> - <br /> -____-- <br /> ------ ---- <br /> rop. -- ------ <br /> Distance to'nearest: Well -------_�`____________"_____Foundation �-� . <br /> LEACHING <br /> LINE No. of Lines Length A each line. ------ Total Length - --_-___-______ <br /> i <br /> 'D' Box --_ Type Filter Material ___ ------Depth Filter Material _____ _ --------- ------ ______________ <br /> V r. e F �- <br /> f Distance nearest: Well _ --__-_ Foundation -- ._._________________ Property Line. <br /> `� - - -- --•-------------- <br /> SEEPAGE PIT �(] Depth ------__---- Diameter _ -f� ----__-----,-_---_ Rock Filled Yes No ❑ <br /> r_ �� ---'--:Number ----- <br /> Water Table Depth -----�*� I __-----------------------Rock Size __. _ .._ r t <br /> Distance to nearest: Well _______ __ _ ___j-----------------Found ation __1A__1------ Prop. Line ".;l--_--_________._. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ________________________________ ___________ Date __-,_____________________________) <br /> *;., l <br /> SepticTank {Specify Requirements) --.---------------------------------------------------------------------------------------- --- --------------------------------------------- <br /> Disposal Field (Specify Requirements) -___---___-_ -------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------ <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: <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 /> - - - --- - ------- - - ---------------- - <br /> BY --------------------------------- --- 1`---�'�.------ ---------------------- Title1 'Z <br /> (If other t n caner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ---- - -------------------------------------------------------------------- ----- ---- DATE --- �O_ w g----------------- <br /> BUILDING PERMIT ISSUED ---- ------ - DATE <br /> --------------. <br /> ADDITIONALCOMMENTS ---------- ---------------------- ------------------------------------------------------------------------------------------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------- --------------------------------- -- ------------------------------------------------------------------------------------R------- }I ------------------- <br /> ----------- <br /> ------------------ <br /> ----------------------------------- ----- ---- ------------------------------------------------------------------ o�� <br /> Final Inspection b ��'• � <br /> �N' ----- ------ ---- -- -------- Date <br /> SAN JOAQUIN LOCAL HEALTW DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. �, <br />