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' '1 QR OFFICE USE: <br /> APPLICATION FOR`SANITATION PERMIT <br /> ---- ------------------------------------ ---------- <br /> (Complete in Triplicate) <br /> Permit No.�__-"_7_ <br /> ---------------- <br /> _______.____-- This Permit Expires i Year From Date Issued Date Issued _-( -7� <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 /> JOB ADDRESS/LOCATION -------- -- ----------------------------- ------CENSUS TRACT -------------- ----------- <br /> 11 <br /> Owner's Name ---- ----------------------------------------------- Phone------------------------------------- <br /> Address ----------• s tr.7---�------G�. .------- 16 --- Cit ? ��..-.r <br /> Contractor's Name ---_--£ f''�-�-� ----- __ --_-- -------.License #,;1 '717 __-- Phone . _ : -_-- <br /> Installation will serve: Residence{Apartment House,❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other <br /> Number of living units:___C___-- Number of bedrooms _______Garbage Grinder��___- Lot Size ________-__________________ - <br /> - 9 ------------- <br /> Water Supply: Public System and name -------- ---------GJ - Private ❑ . <br /> --------------------------------- - <br /> Character of soii to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> F <br /> Hardpan ❑ Adobe W Fill Material __---------- If yes,type ----------------------------- <br /> (Plot <br /> _____.____________ - - <br /> (Plot plan, showing size of lot,116cation of system in relation to wells, buildings, etc. must be placed on reverse side.) " <br /> NEW INSTALLATION: - ' Nf <br /> {No septic tank or seepage pit­peitted if public sewer`is available within 200 feet,I [� <br /> k. % S-^ .. ..y,,- -m <br /> PACKAGE TREATMENT d <br /> ] SEPTIC TANK [ ]' Size ------------ -- ------ Liquid Depth -----=-- �' I <br /> Capacity ------ ---------- Type.. --------------- Material=-------------------- No. Compartments <br /> Di stance to nearest: Well•k - ----------------------- Foundation ---------------------- Prop. Line -------- <br /> -------------- <br /> LEACH NG <br /> --------- --------_--LEACHING LINE No. of'Lines '___-__ ------------- Length of IeacWline_ ._ -r_______-- Total Length --___ -------------------- <br /> Type <br /> � <br /> ® ----------•---- <br /> .Type Filter Material ,tt.- .......Depth Filter Material <br /> IQ" Jo nearest: Well _.6 ____ l_Q-___-------- f <br /> ------ Diameter ----------------Foundation <br /> Rock Fi�Filled Yes E] No i❑ <br /> SEEPAGE PIT [ ) Depth ------------- -t------------------------------------- � � � <br /> Water Table Depth .-------Rock Size ----------------------------- --- <br /> Distance to nearest: Well -------------------•--------_-__--...._-Foundation -------------------- Prop. Line ---------__--------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___`___.'--'___'__-- r "" "' " <br /> Date ------------ ---- --- -- ----} f <br /> Septic Tank '(Specify Requirements) ------"s <br /> J' <br /> s - --- ---____-,Y-^-- ---------------------------------•--- <br /> Disposal Field (Specify Requirement -------- --------------- ------ - _-- <br /> - <br /> . r _ <br /> / <br /> ------ - -- ------ <br /> ------ <br /> -�� - <br /> -- ----- -_ - <br /> -�-= -------------------- '------ <br /> - —, r <br /> I herebycertify that I haveprepared(Draw exist' g and required addition on rev side} <br /> fy ,this application and)that the work will be done in accordance with San Joaquin t <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signaturie 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." <br /> Signed ------- - -------- --- Owner <br /> -------------- - -------- -- ---- Title .- - <br /> - --------------- - <br /> BY ---- - ------------ <br /> --------- �" �"--�-�''-�t✓-'c,'r <br /> i1 (If other than owner) <br /> ---------- ------------------- ------------ <br /> i FO Ait7MENT L ONLY F <br /> APPLICATION ACCEPTED B - - -- ------- -- -- DATE <br /> BUILDING PERMIT ISSUED ----- ----------------- -------------- ----- ---------- -DATE -------------- <br /> ADDITIONAL COMMENTS <br /> ---------------------------------- <br /> - -------- ------------------------------ - - - -------------------------------- <br /> t --- <br /> - --- ---- - ---- -- -- - -------- <br /> Final Inspection by: = / � - <br /> 14L <br /> ---------- - Date ----- ------------ <br /> Final <br /> -------- - <br /> '"" SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> E. H.�9'�- 1-'68-Rev. 5M <br />