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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> a s (Complete in Triplicate) <br /> Permit No. __.-- - -__ __9 <br /> ...._...I--------------------------------------------- <br /> ---------------------------___----------..___---------- This Permit Expires 1 Year From Date Issued <br /> Date Issued ----- --- .y".w <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 madeincompliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 2_?01 -----'C--,------QA_f R lR jP- .L ,� CENSUS TRACT 5^'�� <br /> Owner's Name ---------4 --------- _ -_-_ _ <br /> - ------------------------------ --:-- ------------=-•----------- ------Phone --------------------------•-------•- <br /> Address - ---------524---------/(---------MAJ-/V---------5 ------------------- City .... 'h l'ONT�C19--------------------------------•---•-- <br /> Contractor's Name -----Q11tPfvf�_�--------------- --------------------------------------License # ------------- ---------- Phone --------------------_-------- <br /> Installation will serve: Residence rtment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:---- _____ Number of bedrooms -3------Garbage GrinderyJ __ Lot Size --------- <br /> Water Supply: Public System and name - - ------------•----------------------------------------------------------------•------------Private <br /> Character of soil to a depth of 3 feet: Sand'e Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam D. <br /> Hardpan ❑ Adobe ❑ Fill Material __> [`) If yes,type _-_-_--------------------- <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> N <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK: ' ,�+ Size___ I* _- -��.-___ - Livid q Depth -- ` <br /> � <br /> T e ' - ----- - - �D <br /> C spta cit t eat: Well <br /> A-Material_-C0A(R _ No. `Compartments _-2.--_._--_-. 0 <br /> -----------Foundation f f---- Prop. Line --- <br /> LEACHING <br /> -LEACHING LINE V1 No. of Lines ------3------------- Length of each line----. ---------___.--- Total Length ---ZIP_---_-----___ <br /> 'D' Box y�S T f t <br /> ti <br /> Type Filter Material - _��-__Dep'th Filter Material _______ � -_--__--_--}___._-____-___ <br /> 1 Property Line . <br /> -+- <br /> Distance o nearest: Well - _"�'-_----- roundation __ --------------- <br /> SEEPAGE <br /> -+— <br /> SEEPAGE PIT [ j Depth --------------------- Diameter --------- ----- Number -- -------------------- Rock Filled Yes ❑ riNo C1 <br /> Water Table,Depth ` <br /> -----------------'---- ------------==---='---Rock Size ------------------------------- <br /> tq\Distance to nearest: Well -- -_ --{_- :.--------------------'?.__Foundation-"------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prey.-Sanitation Per it#---_- .---------_:`_----- <br /> ------------ Date ----------------------------------- <br /> Septic <br /> ------------------------------ -Septic Tank (Specify Requirements) -`---------------------------------------------------------------•---------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ----- --------- ---------- _------7_-17_ --=:`-____ _ <br /> f <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 Lows,'and Rules and Regulations-of the-Son Joaqvin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that i the pe ormance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to beco bject orkman's Compensation laws of California." <br /> Signed R -------. Owner <br /> By =----------------------------------------------------- ------------------------------- Title ----------- --------------------- <br /> (If other than owner) <br /> I <br /> A. <br /> FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY ------- }- -------------------------------------------------------------------- ---. DATE ------t�j'BUILDINGPERMITPERMIT ISSUED ------------ - --------------------------------- <br /> ---------------------------------------------------DATE <br /> AD,DIVONAL COMMENTS ----------- ------------------ -- ---------- ---------------------------- <br /> _ --------------------------------------------------------------- <br /> _ -� <br /> --------- ---------------- -- -------------------- -- <br /> -- - ------_----------- <br /> --------- <br /> Final Inspe - Date • - ---------- --7-------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.,9`` ` 1-'68 Rev. 5M <br />