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FOR OFFICE USE: - /of Sr �o v? 14�C4 <br /> APPLICATION FOR SANITATION PERMIT <br /> ........_....-....................... .Y.. -. .�..�- <br /> (Complete in Trip##c dte) Permit No. . <br /> --------------- This Permit Expires 1 Year From,Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for q permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS LOCATION uQ`-i."r �� � �G. �G� hh <br /> / ...� .. .... ....... ........................�ldti--..b�l�r,.. - .CENSUS TRACT <br /> Owner's Nome m �t7�A � �'� .��� � �!W.:OM J —hone lPg <br /> Address : =-City_ <br /> ;. <br /> . : .. _ r.. <br /> Cotittcarto : S i.. d 1 <br /> I ..- ......... --•� - -- .Lien -e` Phone '�lo�.r.:`�,_(o. <br /> Instoilation will-serve: Res'rrdencedApartrnent'Houset] Commercial QTrailerCourt - p <br /> h .... Motel ❑.:Other.... <br /> number of livin units :- Niumb6r of bedrooms_ � ..Garbage Grinder. c t �-�����A i4r <br /> I 9 .. - ..Lot.Size.,._.. =. . . .. <br /> Water Supply Public System and name i Pravate ` <br /> .- .. ... <br /> Character of soil to a depth of 3 feet: Sand 0 Silt[] Clay ❑' Peat[] Sandy Loam ❑ Clay Loam❑ } <br /> ' <br /> Hardpan Il Adobe' Fall Material If yes;type . <br /> # � .. } <br /> r t <br /> Plat:p.. ._. ...k g. . . =.,. , i. . -,, . , . ., , ••_.'_:. ..., i� .,..�. ... - ,.•. .... <br /> (F lan showin -size.of..lot, .location,of .system .in;relcition to avelli,buildings, etc"must.be placed,onreverse, side:}; <br /> NEW:INSfALLATI4N: (No septic-tank or;see <br /> p9ge pit:permittedjf_;public sewer is available within 204 feet,}! <br /> F PACKAGE TREATMENT [ J SEPTIC TANK:f ] Size _-j �w1. ... .. Liqu d :Depth.... Y2. I. <br /> Capacityf� Typee Mpterial.- rte . . Na tampartments , <br /> Distance. to nearest: Well ...... � ' ' Foundation �L... � <br /> Prop. ine .. ._`-. E <br /> LEACHINO'LINE' No. f Line , ... ;;_ ............ ,., �. <br /> j o s Length'o#' each line._-__- - Total Lerig'fh. ..- r <br /> 'D* 'Box ...:L_' Type'Filter Material-579-----�.'_Depth; Filter Material <br /> r ` <br /> I ` Ff)istance to nearest. We --- Foundation ...--- :. Property Line ------- <br /> SEEPAGE <br /> � <br /> SEEPAGE:PIT ..DeptF .Diameter <br /> Nurttber ?_ _ Rock Fiiled,..'Yes•M ._No -i <br /> , <br /> Water;('.able Depth .. - . ._ ........... .Rock Size :. .... <br /> Distance to nearest Well ... _ dation op <br /> Faun Pr 'Line <br /> REPAIR/ADI)1T10N(Prev. Sanitation Permit+# Date ........ <br /> Septic Tank: (Specify Requirements) ............. ------Ev_�__ .............. ; <br /> 0., ... . .. . . <br /> l Disposal Field ;(Specify Requirements) ---- -- •------- ------------------ --------- ....... <br /> :....................'.--- <br /> ...... ..-:.. ... . -------- . ..`. ..: .... .. e <br /> ....................... r....... - - -- :: :: ::: ` t.. .. <br /> 4.1 (Draw existing and required addition:on reverse side} <br /> ,........1. <br /> I 'hereby certify that I have prepared this Application ani! ;that the work Wil€ `be•dono in (accordance with San Joaquin <br /> r Caurity"Ofiiinances, State Laws;'grid Rules a'nd Regulations of the San Joaquin,locof Health district.:Horeie avvri "or((reit <br /> sed.aets.si nature..Aertifies the fol[owin ..� <br /> S 9 � g:` <br /> certifythat in the erformance of the work for vVhl&this`permit is issued, i shall i+ot employ any person in such manner <br /> as to became subject to oikman's Compensation laws,of California." <br /> Signed :. 61 :-: -• ' " -= = Owner : <br /> BY . . --- i Title . .. ' <br /> .... <br /> (If o#,her than owners ' <br /> FOVI)EPARTMENT USE ONI;.Y .r. 4.... <br /> r <br /> APPLICATION-ACCEPTED BY : 4 i <br /> t _ <br /> _ DATE '-'�._ <br /> BLIILDING:•PERMIT ISSUED;... <br /> ADDITIONAL COMMENTS - ; <br /> %-- . .. ..... ..:.... . ... -- ....................t ° AT .. ...-•-•-• " <br /> e .. -- _ _ . <br /> Final Inspection by: . ._ GZ� . _ -'-s...• <br /> ` SANRJOAQWN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M x•� 7172 3",M"- <br />