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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------ - <br /> --------------------------- ------------- (Complete in Triplicate) Permit No. �a_-S_7,7 <br /> ---------------------------- ------------------------- <br /> Date Issued _�-.._-__7(Q I <br /> This Permit Expires 1 Year From Date Issued <br /> ---------------------------- -' <br /> A <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> / . <br /> JOB ADDRESS/LOCATION .--- �_ lP- ----- � `__-`"""., CENSUS TRACT _------------------------- <br /> '0 <br /> -�_---- - - t <br /> 'i ��'l Gr -----Phone .1/_- ,1__ . <br /> Owner's Name ------ - <br /> (° ^t .L• f ( City --------------------------------------------------------- <br /> Address { <br /> ----------:: =� <br /> `` / License �1------ Phone :46. 7g� 7- <br /> Contractor's Name --------------- ---• -- - --- 3-- # _,_..- <br /> Installation will se ve� Residence'(�ApartmentiNousen'Com-mercial :❑Trailer Court <br /> ` Motel ❑Other _ �- o�_� <br /> Number ' �► ---------------------------------------- <br /> -Grinder <br /> --- -----------•---------------- <br /> of living Jnits:-_-2/___ Number of bedrooms ___'___Garbage-Grinder•-�-----Lot Size _.----- -- <br /> t I <br /> Water Supply: Public System and name ------------------ ---- -- ----- ------ ---------•------ •---------- Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat E) ~ Sandy Loam ❑ Clay Loam.[] <br /> _ Hardpan ❑ Adobe Fill Material -- -i_1-sIf 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 permitted if public-sew_rtis available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-- --------------------- ------ - Liquid Depth -------------•------,----- <br /> Capacity ---- --------------- TYPe ------------------`.Material.., -----------------Mo. Compartments -------- -.---- <br /> Distance to nearest: We11l\'IA--------------------------------Foundation ---------------------- Prop, Line ------------------ <br /> ---- <br /> LEACHING LINE [ ] No. of Lines _________________�F Length of each line--------------.------ ------ Total Length ---------------------------- <br /> ` _De Depth Filter Material <br /> 'D' Box .--- -- Type 1'ilterjMaterial -------------------- P ---------------------------------------- <br /> Distance <br /> ------------------ --------•-----••-Distance to nearest: Well ------ ------- Foundation ------------------------ Property Line --------- ------_------ <br /> SEEPAGE PIT [ ] Depth ----------------- <br /> ___ Diameter _________ --- Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth -------------------------- ----- ------------Rock Size -------------------------------- <br /> - <br /> i <br /> i <br /> �_. Distance to_nearest-. Well ------------------------.--- --------Foundation -------------------- Prop. Line ....__-____._---.----- <br /> REPAIR/ADDITION'(Prev. Sanitation Permit# ------------------------------------------ Date ----------------------------------} <br /> Septic Tank (Specify Requirements) ---------------------------------------------------7---- s <br /> ( 3 <br /> Disposal Field {Specify Requirements) -------- s-- 1, - --------------------- -•--------------- <br /> ��V <br /> �. --- , I <br /> ----------------------------------------------------------------- <br /> __ _ __________________________ _--_____.-____. <br /> -------------------------- <br /> t (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 Son.Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: r <br /> "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of Califdrrda." i <br /> i � t <br /> Signed ------------------------------ --------- = -------------------`Ow or . <br /> BY -------- Title <br /> {If �ero nerd t <br /> s FOR DEPARTMENT USE ONLY <br /> APPLlCAT10N ACCEPTED BY = --------------------------- 7------------..------- DATI _ -3° '------------------ <br /> BUILDINGPERMIT'ISSUED - - ------------------------------------------------------------------------------------------------ ---DATE - ----------------------------------------- <br /> _ '7�� <br /> .ADDITIONAL COMMENTS __�..- -----�--��-�----- --: 3n---•--------'•-- ---------------- --------------------- -------------------- ------=--------------------------- <br /> -------------------------------------- ---------=------------------------------------ti--------- ---- ' <br /> E --------------------------- <br /> --------------------------------------------------•--------------------------------- ---- fi�3-------------------- = <br /> --------------------------------- - ------------ -------------------- --------------------------------- --7_01 ------ <br /> SAN <br /> . <br /> Final Inspection by: e« ice --.Date -- �a----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />