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� ten, .- �� ii•i,R'�._ .- -' ! <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---- ----------------------------- Permit No. <br /> ! (Complete in Triplicate) <br /> ► e,.. <br /> This Permit Exp ire�1 Year From Date Issued Date Issued ______ -;[1- _.. <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 C6vAty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ��l - 77-- `' r ; ;� U------------------- ----------CENSUS TRACT --------------I----------- <br /> ----PhoneOwner's Name -._. <br /> -7 - <br /> Address --------------- ------ <br /> -7 7-7 1 :z City �`�'� <br /> Contractor's NameP-----AA-ZI� ----=------ ---------------- License # ,� Phone _ C1 6Q <br /> •*,, <br /> Installation will serve: Residence Apartment Houe[].Commercial :❑Trailer Court ;❑ <br /> f e f�► <br /> Motel ❑ Other -------€----=- - -' <br /> Number of livin units:__ _._____ Nu' � t <br /> g tuber of bedrooms ___.l____tGarbage Grinder __ - "" Lot Size .... <br /> !_-/'x'-------------------------------- <br /> iV Private <br /> Chateacserpofl soP Lala depth of 3 feet:ic System and meSand'❑ S'lt❑ y. ❑ Peat❑ Sandy Loam Clay Loam <br /> - 'Hcsrdpern E] Adobe'(] FHIMaterial -------------- If yes;t e <br /> YP <br /> (Plot,pldri showing size of,lot, location­of-sys4 inH relation-a`o'wells, buildings, etc. mus0be; placed on reverse side.) v <br /> NEW INSTALLATION (No septic tank or seepage-pit permitted if public sewer is available within 200 feet,) <br /> ► . <br /> Ilk <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size-f'---------------------------------------- ----- LiquidtDepth -------------------------- V <br /> Capacity J _------_--- Type - ............... <br /> ---------- Material------------- -------- No. Compartments --------- -------•-•-- <br /> Distance tot nearest: Wel! ___-____' __________" ___________Foundation _.__ ---- _"__________ Prop. Line -----------._.:..______ <br /> LEACHING LINE 1 ] No. of Lines _____________________7, Leng h of__each line---------------------------------- Total Length ---------------------------- \ <br /> 'i5.p <br /> •4 i: <br /> 'D' Box ---- ...... Type Fitter Materi 1 --------------------Depth Filter Mat vial -----_-----------------.-----------•------.- <br /> - <br /> V Distance tonearest; Well ______________ _________ Foundation _______________ _ Property Line. ----------_------- <br /> . .. . <br /> GE PIT <br /> } Depth __-] Diameter Number __________ Rock Filled Yes E] No <br /> SEEPAGE <br /> Water Table Depth ----------------------- ---------------=-- -----Rock Size --- ------ ----------•-------- <br /> . <br /> _ .-„_ S . <br /> Distance to nearest: Well -----_.- _______________"""_--Foundation --------- ________ Prop. Line .._______.........."_ O <br /> REPAIR/ADDITION(Prev. Sanitation Permit# __________________ _-----.-------""--- Date ____________________ __________-� <br /> Septic Tank (Specify Requirements) ------------------ --------------------- <br /> f� _ - --- --- <br /> Disposal Field (Specify Req __-- ------; �-�---- `------ ---�----------- ---•--------------- <br /> ------------ 1------------------------------------------------- --------------------------------------------------- --------------------------------- - <br /> — [Draw existing and required addition on reverse side <br /> d <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 Hcen- <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'sr Compensation laws of California." <br /> Signed ----------�------------------- ---------------------------------------------------------------- Owner <br /> BYv `� 0 Title - U�T`--------------------------------------------------- <br /> (If other n owner) <br /> FOR(DEPARTMENTpUSE ONLY <br /> APPLICATION ACCEPTED BY ------ T R' --------'----------------------------------------------------------------- DATE ---•- �7Z�... <br /> BUILDINGPERMIT•ISSUED ---------------------- -------- ---------------------------------------------------------- --- ----------DATE -------- ------------------- -------------- <br /> ADDITIONALCOMMENTS ------- --- ----------------=---=- ------------------ ,--------------------------------------------------------- --------"---- ---------------------------- <br /> ----------- <br /> -- -r_ --- --t---------------------------- ---------------------------------------------------------------- <br /> ------------- _________..__________ _ _________ . ______-____ __ __-_____"_ R <br /> - ------- - --- - <br /> ---------- - --- � <br /> Finallnspec ••------------------------------Date ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �{ <br /> E. H. 9 1-'68 Rev. 5M• tdr <br />