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FOR-OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> __. ..-�.,�.... . . ,_ :...., .,e.- �, ,permit No: - --- ' <br /> r1: SI�[�� �, (Complete in Triplicate} ! <br /> ____.__.________._ This Permit Expires 1 Year From bate Issued <br /> 4 _1A - -------------- - ------ z/ <br /> G/ <br /> 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 Ordinance No.�4 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .��.�7 ta, ', _ '�:iQ_ ,ct, r __ .S.. .1,I <br /> �/ ,/ r --- -CENSUS TRACT <br /> r/ i/ <br /> Owner's Name ------ : --------- ----- ---------------------Phone _"- _-?�F4's -_ <br /> Address _.._ L /. t`''. ---- { <br /> Cit - - -Q <br /> = : , , <br /> Contractor's Name- _5ls ��J' - «e`7; -x �L!'C----------License # -------- ------ Phone ------------------------------ <br /> Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court ❑ r <br /> Motel ❑Other ------------------------------------------- 1 <br /> Number of living units:________ Number of bedrooms Zj_____Garbage Gri er ------------ Lot Size ?_7_ � <br /> X_4 -.. --_____ _ <br /> Water Supply: Public System and name __ - & _ ✓i.S -_______-__ _-_________-_____Private El '\ <br /> j Character of soil to a depth of 3 feet: Sand'Q `Silt^❑ Clay .❑ feat❑ Sandy Loam .0] Clay Loam E]Hardpan [j '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.) _k <br /> NEW INSTALLATION: (No septic tank or seepage pit permittedif-public s er is available within 200 feet,] � <br /> i � t <br /> PACKAGE TREATMENT [ ] SEPTIC TANK e. F Size.______._ 25, 9 3 !r-- Liquid Depth ____ ?_.SP__._____--_- <br /> Capacity.. Q._p +' __ Type �l�e.- `iit, __ Material___.EexNo. Compartments ----- ......`' <br /> r Distance to nearest: Well ________________ __ _____Foundation _._1______.._1-..___ Prop. Line -------.____.'_.______ <br /> LEACHING LINE Af No. of Lines __-__-____' $ Total ten ---_--9 r'i <br /> t_ . Length of each line___-____ Q Length a - - --- i <br /> % <br /> t <br /> 'D' Box -------- --- Type.FilterL-Material�� S Depth Filter Material ______ "-__._._ <br /> ! --------- --------- <br /> t . �-- . <br />! <br /> Distance to nearest. Well �o 4�`t.".`_____------ Foundation .l_f.�_ ____________ Property line ------__ __.._.__._.._. <br /> SEEPAGE PIT Depth - .+ Diameter. _"Z___ Number ____- 1------- ------ Rock Filled Yes X Na i❑ <br /> Water Table Depth -- --i---------------------------------Rock Size ----------- <br /> 01 <br /> j <br /> A, lte-rDistance to nearest: Well ____________________Foundation -----/_0__: Line --------a ..__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# - ----------------' ._-._____.--_.-__._.e__-Date�__�--:_- <br /> SepticTank (Specify Requirements) -------------- ----------------------------------------------------------------------------------------------------------------------------- } <br /> Disposal Field (Specify Requirements) ______________ .______________.___-_.___.--.___-_--------- <br /> ---------- --------- ------------------------------------------------------t --------------------------------------------------------------------------------------------------•------------- ------ <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 /> "I certify that in the performance of the work for which this permit is issued, I `s`hall.not employ any person in such manner <br /> as to become subig�t to Workman's Compensation laws of California." <br /> '`fel d t <br /> Signed ---1 - A/ !' - �----0��----Svc..------. <br /> i By ------ ---------------------------- ------------- ---- -- -- <br /> Title <br /> ------------------------------------------------------ i(If other than owner) 4 <br /> FOR DEPARTMENT USE ONLY <br /> . 1 <br /> APPLICATION ACCEPTED BY _ __ __________ ti [ f <br /> ----------- -- ---------------------- -----•-:-----------.,DATE <br /> ---------- '--- _�1_L3-- ------------------------------ <br /> BUILDING PERMIT ISSUED ------------------- - �-------- '-"-----------DATE ------- -------- --- - -------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------- -- ------------------------- ------------------------------------------ <br /> ----------------------- ------------------------------------------------------- <br /> -- ---------------------------------------------------------------------- <br /> ---------- -- ------------------- ---- <br /> - <br /> Final Inspection by: ------ :---- V°"�---------------- ------------- <br /> ----------------------------------------Date -- -- --- --�'- - -- -- --------- � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />