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FOR OFFICE--USE:: <br /> APPLICATION FOR SANITATION PERMIT <br /> ,V----------- Permit No. - d <br /> (Complete in Triplicate) ' <br /> ----------1_,'_,a---- ------------------ -------- ------ <br /> R <br /> s 7v <br /> ----------------------------•------------ ------ <br /> --_- This.Permit Expires I Year From Date Issued ate Issued .__.� ___"____. <br /> } <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrdct and install the work herein <br /> described. This application is made inn'c pl c it>;o� ty,Prdinance No. 549 and paxitting�Rules and Regulations: . <br /> JOB ADDRESS/LOCATION <br /> • � o, / D ,°t� - e,SjlJ DC.t CENSUS TRACT -------------------------- <br /> Owners Name _-- ! "`- €- -Phone <br /> -- - c� � . <br /> a -----------••--•- - <br /> Address . ✓ 1 � � 'Giky .f /a' -- <br /> Contractor's Name _- -_•__ - -- >r ------------=-------License # --- Phone _�_'_ � � <br /> Installation will serve: Residencet(�partment House❑ Comm ercials❑Trailer Couri l❑ <br /> MotO❑Other --------------------------------------- <br /> Number <br /> ------------- -----------------------Number of living units:_.. -------- Number of bedrooms _A Garbage Grinder Lot Size4 ----------------- <br /> t <br /> Water Supply: Public System and name ... 4'--------------------------------------------------------------- = ------- -Private <br /> Character of soil to a depth of 3 feet: Sand Silt ❑ Clay ❑ Peat❑ Sandy Loam` [B" Clays Loom [] <br /> A: <br /> I Hardpan E: Adobe ❑ kill Material -.--- ------ If yes,type ---------------------------- <br /> r <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 seeps a pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK�(7 Size7°��X_`�_ _X_ V-p--------------- Liquid Depth -------------- <br /> PACKAGE TREATMENT <br /> Typ ------ Material ��`�72-____ No. Compartments ---•............. <br /> D.istance'`to nearest: Well dation /�________________ Prop. Line _--'__.___________.. <br /> LEACHING LINE (G�N'o, of Lines _. -.MY ---- Length of each line...6-0----------- ------ Total Length L_70-__-__________-- <br /> i or. <br /> __-Type Filter MateFidIAX_'X_-_____=Depth Filter`-=Material _N--------- <br /> `D' Box,.:� - -------------------------- <br /> e— <br /> Distance <br /> ------------ - ----- <br /> Distance t2-nearest:-Well------------------ -__--Foundation,;/ ---------- Property Line ---------------------- <br /> SEEPAGE PIT De th Diameter _________________Number -----------------.---------- Rock filled Yes ❑ No 0 <br /> Water Table Depth -------- ----------- -----------------Rock Sire -----------------------•-------- <br /> # � _4-Ze,�t.rt. ..�. .r . —w . 5." <br /> - \....... Foyndation -------------------- Prop. Line ---- <br /> Distance.to nearest:.-Well -._ , <br /> *EPAIR./ADDITION(Prev. Sanitation-Permit# ---------------------------.. ' -_s pat •------------ -•-------} <br /> 't I4._ <br /> Septic Tank (Specify Requiremenfs).-_.--.-'--- i---------- --------------------------------------------------- -------------------------------------------------------- <br /> a <br /> Disposal Field (Specifyr Requrrements} -- <br /> ----- •---------------- ••---------------------------------- ------�-------------------------------------------------------------- <br /> .. <br /> 1 1.is <br /> - -------------- <br /> r 1----------------------------------------------=------------- --------- =------� ---- -------------------- .- _ _ . <br /> - -- <br /> I (draw existingiind required ddditio on reverse,,slde") ' <br /> I hereby certify that I have prepared this appl.i ption,and 1that' the work will be-dene in 'accordance with San Joaquin <br /> '4V ",€ <br /> County Ordinances, State;Laws, and !Rules and Regulations of the SanJoaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: I <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 ` � x -------------- <br /> By ---------- -'d=--- J <br /> (if other than owner) t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCE=PTED -BY - -------- - ---------------------------- ---------------------. DATE -----�---------------------- <br /> - ------- <br /> BUILDING . = =---------DATE------------------____------- <br /> ADDIT�IO_N.AL rC-OMMLNTS - ✓� <br /> -------------- <br /> ------------------------- <br /> ---------- <br /> ---------------------- <br /> ---------------`- <br /> - <br /> ------------------------------------------------ <br /> r <br /> ---- ---- -. ----- <br /> --- <br /> --------- -- -- --- ------ ---- <br /> ---:- -------- - - ------ - ----- <br /> - ---._Date Inspectioy - - _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />