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FOR OFFICE USE: <br /> - -------------- ----- <br /> APPLICATION�FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. "7f-'-5_-_----. <br /> ' ,:- This Permit Expires 1 Year From Date Issued Date Issueda7�?/. <br /> t It -; <br /> Application is hereby r66de:toW San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application+` mdd,e,in compliance with County Ordinance No�j549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._.- ? .-- ---- ----.------ -----t --- <br /> ---------- <br /> -_ �.--- CENSUS TRACT --------------------•----- <br /> Owner's Ntame _ _- <br /> B r <br /> Address __'3_. '_81. 7 <br /> Pho 60 <br /> r=v -` --- - ,; ------------------------- Cit - - --------------- <br /> --- - - -- -- --- --- <br /> } - - =�r Y ----- --------- �.-� Phone ��-�/ D b <br /> Contractor's Name _____._.---_ -- - _ -� � -- -_- <br /> - .License # -f-.--.___.�/--__--- <br /> Installation will serve: " 'i� Residence, Apartment House❑ Commercial ❑Trader Court Cl <br /> Matel-D:�Other ------------ <br /> Numberof living units:_.--/___-:- N m b ofTbedrooms ---------"'GarbQge Grinder ------------ Lot Size ---- _ � <br /> -i=--------------•--...--- <br /> Water Supply; Public System and name _----------+ <br /> Private <br /> Character of soil to a depth of 3 fe�"°� S d'❑ Silt❑ Clay' ❑ Peat❑ Sandy <br /> Loa -F] Clay Loam i <br /> �H�ajrdpan E] Adobe'❑ Fill Material ------------- <br /> If.yes,type <br /> (Plot plan; showing size of lot, locition sof system in "elation Ito weds, buildings, etc. dust be placed on reverse side.) <br /> NEW INSTALLATION: ' <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> � ,� / /+' ' <br /> PACKAGE TREATMENT Size-_-a ,Z(- -------- - ------------------ Liquid Depth I---->W--_-----..- <br /> [ ] SEPTIC TAMC� �/I,, �, - <br /> Capacity _#_---._-_ Type __`__ Material_---L� No. Compartments <br /> Distance to nearest: Well -----1 > ___-'�-. .-_ -----Foundation ......./0' _--- prop. Line _____----- <br /> 1 ) ---------••- <br /> LEACHING LINE M No. of Lines ________ ____ ------- Length of ;each line_---.- _ ---------"--- Total Length _-! ,------_...._-___ <br /> Box :_._- T e�,Filt Material -- <br /> ) YP 4� I 1 ----.Depth Fitter Material -----jf ------- ------------------ k�l <br /> ----- <br /> Distance to to nearest WeLI 1"_- 11 f--____-I Foundation __.A0_'f--------- Property Line -" -- --..-_------ <br /> SEEPAGE PIT Y due Jf h � `) 'm l <br /> p _�.�__--- -". Diameter - _-"�---_�_ Number -------/----------------- Rock Filled Yes No iQ <br /> Water Table Depth ----------I--------I--------- <br /> Distance tot nearest: Well, Rock Size <br /> -------------------------------- <br /> l -____-_-- -_- ---- --------------Foundation ----------------- Prop. Line .-------..-----I-- . <br /> REPAIR/ADDITION(Prev. Sanitation!Permit# --------- - - _-. , .-________ Date <br /> Septic Tank (Specify Requirements) ------------- <br /> ----------- <br /> Disposal Field (Specify Requirements) _______________________ ____________ ______________ <br /> --------------------------------------------------------- -------------------------I-------- ----------- I--------------------------- - r <br /> ---- ----------------------------- -----------------------------------q-------- --l-=----------------------------------------------------------------.......--------- ---------- <br /> (Draw existing and re uired 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,'an'd Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the Following:I <br /> s <br /> Ls"I certify that in the performance of the work For which tpermit 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 /> BY ; C�= � ------------------------- ------------ Title --------- <br /> (If oth an owner) <br /> - FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ---- - ---------------- - ------------ -------- DATE <br /> I DING PERMIT ISSUED --------------= i l ----------=--------------DATE <br /> ADDITIONAL COMMENTS -------------- ` } <br /> ---------------------------------------------------- -------------------------(------------I----------------------- <br /> ----------- <br /> -------------------------------------- --------'----------------------------------- <br /> ------) <br /> -------------------------------------------------------- <br /> t i <br /> --- --------- ------------ <br /> Final fns tion b „ <br /> --- -------- <br /> ' --------- .Date '.___ `71.-- -- __--- <br /> ` `'� �rOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />