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-SFOR <br /> �,,� APPLICATION`FOR SANITATION PERMIT q ,/ <br /> r I Permit No-- ---------------------- <br /> (Complete 7` <br /> I in Triplicate) <br /> ----------$_E'k-5` '-l��l------------- at,:,,` 1 f <br /> �` r- Date Issued _._� "lG_.� <br /> _______________________-_#_______-._-____-____________ This Permit Expires 1 Year From Date Issued <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 /> ADDRESS/LOCATIOf . <br /> �OSQ_ 1-AWr __r s q-615-1 � ��`�'kT� CENSUS TRACT --------------_---------- <br /> JOB <br /> Owner's Na a --------------------------------------------------Ii- - ...............................---------------------Phone ------------------------------------ <br /> q <br /> Address Q_ 1�.'OU_- SAKE ) 4 40 1J. C'AL.IFOV,01A Cit �,r rc>��r-t,nD <br /> x <br /> Contractor s Name /��( <br /> _ c y - $ - - - ------ ------------------------------------------- <br /> WAG* 5eWh __DVgRaP 'C®.------License #�//� 5+f1---------- Phone 4616--3841 ----•-- <br /> Installationiwi� rve: ResidenceApa4 tment House❑ Commercial ❑�ratiler Court ❑ <br /> 4 r Motel F-1 Other <br /> r a4 { <br /> _ -------------------- ------------------ <br /> -_ 1g `------ Number of bedrooms ------Garbage Grinder N�r___-_ Lot Size 7 X--�'-�-- --_______________ <br /> Number of livin.' units:-- <br /> rfi-,� "'', ;,q SG21�1� <br /> ViVater Sup14y;.�blic Syst m and name CAF-OS21.]I A__-uIJ Y ' ,+------- -- ----- - ----------------------------Private ❑Character of soa depth�of 3.feet:, 5and'[J Silt❑J Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> i ., { '` <br /> HardpanT❑ Adobe Fill Material KO---- If yes,type ____________________________ <br /> ;(Plot plan,lsho ing�size of;,lot,.,ldcation of 'system in relations to wells, buildings, etc. must be placed on reverse side.] d <br /> I f_-, I - <br /> NEW INSTALLATION: (No septic taA k or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT.....]...,..,SEPTIC_TANK [ ] Size------------------------------------------------ Liquid Depth ----------------_.---.___-- <br /> I Capacity ------------------ Type _ Material---------------------- No. Compartments <br /> Di"s'Yance*to"nearest'"Well—__-_=l---- ~---------- -------Foundation ------------------ -.Prop.-Line <br /> LEACHING LINE, [![� No. of Lines -----€ -_._._'"_ Length of;each i eE _ro *------------------ Total Length ----------------------_----- <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ___________________ . <br /> Distance to nearest: Well _______________________ Foundation ----------------------- Property Line ______-__._--_-_-_:---- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No ❑ <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) _X'7���T_ t0- a A`% _-#. �7 _------PQ>��a1'i"---5Y5rem------------------- � <br /> -------- © 111?_ 1,� -7� �1F I.--11,0 --- -!_}its- ri D_4_ � pl 2 ------- <br /> (Draw existing and required addition <br /> ----- ------- <br /> clition on reverse sidel <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 /> "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." i <br /> Signed - --- ------------------- -------------- -------------------- Owner <br /> By ------ --- -- ------ Title ----- ----------------------------- -r ------------------ <br /> j <br /> ---------------------------------- <br /> (If other than owner) <br /> EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------i --u.- --------------- DATE �� "'6 <br /> BUILDING PERMIT ISSUED _------- _-__ DATE ------------------ --------------- <br /> -- -- --------- ------------- <br /> DITIONALCOMME -----.-- t - ------------------------------------ --- --------------------=--------------------------- <br /> '" r� ----------- — ------------ -- -------------------------------------------------------------------------------------------------- <br /> ------------------------------------------- - - ------ -- ------------------- ------------ ----------------------------------- -------------Z_­_ <br /> Final Inspection by: ---------- --------------------------- ------ --------------------------Date —J�= ------------------ <br /> SA AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />