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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT / <br /> ---- <br /> (Complete in Triplicate) Permit No. l(l�-•_ ____5 <br /> ---------=----------------------------------------------- ' <br /> � <br /> Date Issued ": <br /> I <br /> --------------------------- This Permit Expires i Year From Date Issued EE <br /> E <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 /> e <br /> S � <br /> � <br /> ._°A '- - --t- <br /> --- <br /> JOB ADDRESS/LOCATION • Phone <br /> Owner's Name --- - - <br /> Address4 � Q ---------- City i5_Fp 1vr-------------- ------------. <br /> -------- <br /> --------------------License <br /> -------_______.License # Phone <br /> Contractor's Name ____ .__ <br /> Installation -E] <br /> will serve: Residence �artmentHouse❑ Commercial :❑Trailer Court❑ F. <br /> . ^;,•Motel ❑Other -------------------------------------- <br /> I { i <br /> Number of living units:_____ 97 <br /> _____ NuJn'nbe�ot-berooms _-_0-____Garbage Grinder -- �� <br /> x .a_ Lot Size # ------- <br /> Water Supply: Public Systerxi and nd e s f _ '�1pu.�4----_. — -------- - -ivate - -� <br /> PV _.- -r_ Private <br /> Character of soil to a dept"i-30 <br /> i of;3 eet: -Sdnd' Silt�~ Clay `•-Peat❑- Sandy-Loam'-Q JClay Laam.;❑ I _ <br /> " F ardpan ❑ Adobe ❑ Fill Material 1VA9--- If yes,type ---------------------------- <br /> (Plot plan, showing size ofy lot, location of system �in relation to wells, buildings, etc. must beplated on reverse Iside.) <br /> NEW INSTALLATION: (No'septic ank or seep pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT { I SEPTIC,TANKT � Size_`$, -_ i!=° 9__X____ ___________ Liquid Depth -----4.. <br /> W <br /> F Y Ty ��J } <br /> Ca aclt '_____ T (�- ___ �e'rial'� -_ No. Compartments ____o�.�.. `�.. <br /> k � � <br /> CICO:.__ �____ _ <br /> # s �� ol 1 fi ifJ <br /> Distance to:nearest: Well ___ _a__ _=______ ±____foundation -------- PrOp. Line ----- _ _ . !___ <br /> LEACHING LINE ( ] Nod of Lines l g r g � <br /> -- �- - � Length of ------------ Total Length -----`�c��---{.__,e.1-- <br /> 'D' !Box Type Filter 'Material -_- __ .___ --_Depth Filter Material ______ q_- _,_ ._. _ _ <br /> i ' f I ) '""°".'� <br /> Distance to nearest: Well -- _ __ _-__ Foundation ------------ Property Line <br /> SEEPAGE PITS[ J Depth <br /> ___--r_-`:-- --___-- - Diameter ---------------- Number ---------------------------- Rock Filled IYes Nto,;..o <br /> _e <br /> t1 <br /> Water Table! Depth ------------ 7------------------------------Rock Size -------1-7=----------•---•--- va <br /> Distance torlearest: Wel! -----{-------------:--------------------Foundation -------------------- Prop. Liffe .---.-•--_-............... <br /> REPAIR/ADDf,TION(Prev. Sanitation,Permit# -------------------------------------------- Date ----------------------------------1 <br /> Septic Tank (Specify Requirements) -------------------------------— �_._._.._..�.. `-------------------------------------------------- '----------------- ........i <br /> Disposal Field (Specify �- <br /> Requirements) --------------------------------------------------- ---------------------------------------------------- --- --------- <br /> k j r <br /> r _ �awa...r� <br /> —# ----- - --- -- ------------ ------- <br /> I <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 Joidquin <br /> County Ordinances, State 7:itws, and Rules and Regulations of the.San Joaquin Local Health District. Home owner orlicen- <br /> sed agents signature certifies the following: ° <br /> f <br /> "I certify that in the perfoiehonce 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." 1 <br /> Signed ----------------------------------------- „ ---------- 6J Owner <br /> --- - ----- -------------------------- Tite -----BY ---- ------------- <br /> (if <br /> -----------: <br /> (If <br /> I <br /> other than owner) <br /> FOR DEPARTMENt USV ONLY # <br /> APPLICATION ACCEPTED BY --- - i_R._-0'-___ -----------�-------- I' <br /> = DATE j <br /> BUILDING PERMIT ISSUED ----------- 4 -- -------DATE ----------------------- A----- --------- <br /> -- <br /> -------- I <br /> ADDITIONAL COMMENTS - - = <br /> -- -------------------7---------------- <br /> k <br /> ------------------------------------------- -- -- ----------- ---------- ------------------------- -----------------------------------'---- --- <br /> --------------------------------------- ------- --------------" ------------------------------------------------------------------------------------- <br /> ----------------------------------- ---------------------------------------------------------- <br /> Final Inspect! n b --------------.Date -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />