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FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No: 7 - 7 - <br /> (Complete in Triplicate) <br /> This Permit Expires I Year From Date Issued Rate Issued _ _Z:_7Z <br /> Application is hereby made to the Son Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in��77 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ./� Y/;Q -----1.co,�-------- ------------------------------CENSUS TRACT ---------------•--_---_ <br /> Owner's Name --cGs+_-`-=---- 1 --------------------------------------------:---------------=- -------------------Phone ------------------------------------ <br /> r <br /> Address ��� --------------'L4-�------------------- City ---� �' <br /> Contractor's Name -____--_ ---- ---------------------------------------License # __ .2/ 3-- Phone <br /> r <br /> Installation will serve. Residence Apartment House_,❑..Commercial:❑Trailer Court HCl <br /> [f Motel ❑Other -------------------------------------------- # <br /> Number of living units:------- Number of bedrooms ___:Garbage Grinder -N`J___ Lot Size _ ___ ___L ___________________ <br /> -_--_ -, _ �-L_ __Private ❑ <br /> Water Supply: Public System and name ----------- ------ .. - ---- -- ------ ----------------------- - ---------------------- <br /> Character of soil to a depth of.3 feet: E Sand'❑ Silt Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam :❑ <br /> Hardpan 0 Adobe Fill Material __i`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.) <br /> NEW INSTALLATION: (No septic tank or seepage-pit-permitted if-public;seweris-available,within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Size----------_--------------------------------------`Liquid Depth --------------------------- <br /> Capacity -----'---------- --- Type -------------------- Material--------------------- No. Compartments ---------•---- <br /> [ I f' ' b <br /> Distance to 'nearest: Well ------------------------------------ <br /> Foundation '}---- -----Y'`.._: Prop. Line ----------= - <br /> LEACHING LINE { ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ,____--_-_-___-__________._ <br /> 'D' Box ------------ Type. Filter Material_____________________Depth Filter Material _---_--_______________-__---_.______-._._..- <br /> i , - A . <br /> Distance to nearest: (Well _.________________f__ Foundation ------------------------rProperty Line ,_____._.__......-_-_-___ <br /> iRock Filled Yes <br /> SEEPAGE PIT [ ] Depth- -------------------- Diameter ------------ --- Number ------------- ------_ - ❑ No .i❑ <br /> Rock Size ---------------------- <br /> 10 , <br /> t <br /> Water Table)Depth -1--------------------------------------------- --------------- ' <br /> Foundation __.______,_ ,. P10 Line _____ ---------------- <br /> Distance <br /> to nearest: Well -------------------------------------- •. : p• <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ______._______-_____-___._r_ ._ -------- <br /> --------- Date -----------------------• <br /> --)` <br /> Septic Tank (Specify Requirements)i ---------------------------__ <br /> -----------------------------------------•---------------------------A-------------------------- <br /> Disposal Field pecify Require ants) _______may- if'rr _----�V--¢- -------- -- ----- -- -=-=•--------------- <br /> ------------ - -------- -.- - - e - <br /> ---------------- C-------- S ------------------ --------------------------------------- <br /> (Drawexist� 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 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed _.. ---- ------ -------------------------------------------------------------------------- Owner <br /> r - --- <br /> ° Title �`-�---� <br /> t er than owner) <br /> E i <br /> i , FOR DEPARTMENT LIS ONLY ,{ <br /> APPLICATION ACCEPTED BY -.--- �- DATE ^ ------ --- __--�---- - <br /> BUILDING PERMIT ISSUED ------�------------------- -- _DATE --�-------- <br /> ADDITIONAL COMMENTS ------------------_ "' <br /> -------------------- ---------- ------- ------ ----- --------- --------=---------------;------------------------- ------------------------------------------- <br /> - . ----- <br /> ---------- - - <br /> _ Date _ ------------------------------- <br /> Y �------ -Z----- <br /> Final Ins action b <br /> P --- <br /> J AQUIN LOCAL r HEALTH' DISTRICT <br /> 4 l.J <br /> 1-'68 Rev. 5Mr-- <br />