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FOR OFFICE U$Er ------- --- -- ------------ <br /> _• �� �`=' 73'— / �� � <br /> �, � -- Pf.ICATION FOR SANITATION PERMfT <br /> ---------------- - <br /> ..� � .� .� � Permit a. --------------------- <br /> in <br /> (Complete Triplicate} <br /> Date Issued <br /> --------------------- ----------- ----------------------- his Permit Expires 1 Year From Date Issued <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 /> 77 GG 1 r Al, <br /> , ;C oov v td- <br /> JOB ADDRESS/LOCATION .-------S� C._Q._-----�i.(, _j_J_�_/f �------- _-_C7 jp_--f.�% )ZENSUS TRACT <br /> Owner's Name ----- x7� - <br /> --------------- ------- <br /> �, //'' ---- - Phone ------------------------------------ <br /> Address /V � /o`er. _. C� 5 City �J`n-0 - <br /> :.. <br /> Contractor's Name --j.--�.��____-- c_2_ ___________________________License # y Phone ------------------------------ <br /> Installation will serve: ;'Residence impartment House❑ Commercial :[]Trailer Court <br /> Motel ❑ Other ----------- -------------------------------- <br /> Number of living units:---___. Number of bedrooms __� . .Garbage Grinder ---/----- Lot Size -_-_--------------------------------------- <br /> Water Supply: Public System and name ---------to ------------------------------------ --------------------------------------=---Private 59..E <br /> Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type -___--_------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) V <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT X SEPTIC TANW Size-----/- 0_.-.__ ---i1-- Liquid Depth ____.--_--_--__--_-._.._. <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments Z,_----------- I <br /> 1 <br /> Distance to nearest: Well ____________________________________Foundation .________ _ _ ___ Prop. Line _____________:........ <br /> LEACHING LINE ] No. of Lines .___._I--__--.--_-- Length of each line_-J- ,Ot#C')r'' .__ Total Length J -XT._-'D' Box _ +_../__ Type Filter Material -------------------- ter Material --------------------------------------------- <br /> Distance <br /> -------.-.-----_ <br /> Distance to nearest: Well o/ -T------ Foundation _._/0-------------- Property Line <br /> SEEPAGE PIT ( ] Depth -------------------- Diameter ---------------- Number -------------------r------- Rock Filled Yes ❑ No .I❑ <br /> Water Table Depth ------------------------------------------------Rock Size ----------------------•--------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----_-.___.........._. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------- ------------------------------------ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --- -- --------------------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ---------•------------------------------------------------- ------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- ------------------------ <br /> -------------------------------------------- ------ --------------------------- ----------=-- <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 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 /> "1 certify that in the pert ante of the work for which this. p ermit is issued, I shall not employ any person in such manner <br /> as to bet upject o %or�kan'sA"peAafiwfa-iis of California." <br /> �. <br /> Signed ------- ------ ------ Owner ' <br /> By --------I------ --- <br /> ' -------------------------------------------------------------------- Title --------------- <br /> -------------------------------------------------------- <br /> [I of er than owner) <br /> AA OR QEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---C .�_. '-------------- -- -- ----'��-�___ DATE _� _.I -___-.� <br /> -- ------------------------------- -------------- <br /> BUILDING PERMIT ISSUED . ----------------------------------------------------------- ---DATE ---- -------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------------------------------ --------------------------------- <br /> ----------- <br /> ------- --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------- ------------------------------------------------ s ----------------------------- ---- ---- -------- ------------ <br /> - ------- ------ <br /> - -- --- - -- - - ---t <br /> Fin <br /> al Inspection by: ------ ---------------- ------- ------------------------------------ Date - f 7 <br /> SAN J AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />