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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. 7Z_'-4 .g-0- <br /> ----------------------- (Complete in Triplicate) <br /> ._._ <br /> =' <br /> -------- <br /> ------ ---------------- Date Issued <br /> -- ----- ------------ <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the So Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in ompliance with County Ordinance No. 549 and existing Rules and Regulations: I <br /> + <br /> - ------------CENSUS TRACT -------- -------•--- <br /> , <br /> " ---------- ---- <br /> JOB ADDRESS/LOCATI __-----���----- � �-- --------------------------- <br /> .. __- _Phone •------- <br /> Owner's Name yre ��-------- <br /> y ----------------- city . � rte` <br /> Address --Q,:�-� �`/>-f-�../------I--- ----------- ---------------------� --------- - <br /> Contractor's N 'me .__ L'<- = ---------------------------- <br /> License;#y ---� -- Phone <br /> Installation will serve: sidence ❑ Trailer Court ;❑ <br /> Motel 0 Other -------------------- ----------- '- ------- <br /> 1 f ------Garbage Grinder -" Lot Size �r� -------------- <br /> Number of living units:__ Number of bedrooms - F i <br /> pp Y= Public Y <br /> Sstem and ndme <br /> t . ------- --- -- ------- -------------------------------=--------------------------------Private <br /> CX <br /> Water Su 1 _____ __ _ <br /> Character of soil to a depth of 3 feet: yak Silt❑ Clay ❑ Peat El Sandy;Loam -EJ Clay Loam E]�f <br /> I _ Hardpan ❑ `�AdobeX Fill Material __-__._ -__ If yes,type -------- ------- ----------- <br /> _. <br /> (Plot plan, showing size of lot, location. of system,in relation to wells, buildings, etc. must,'be on reverse side.] <br /> NEW IN (No septic tank o.;seepage,in <br /> permitted if public sewer is availcible within 2d0 feet,] <br /> SEPTIC TANK; Sized Liquid Depth --------------- <br /> PACKAGE TREATMENT [ ] }"`t <br /> Capacity -------------------- Type ----- :--------- <br /> Material---------------------- No. Compartments �. <br /> Distance to nearest: Well _'- ---------------------------------Foundation '--- ---------------- Prop. Line ------••---------•-- <br /> ` Total Length ---------------------- <br /> ---------------------------- <br /> LEACHING <br /> LEACHING LINE [ } No. of nes -----------------------_Length,of each line:__: -- -- ---------- g <br />` n <br /> - DepthF Iter Material ---------------------------- <br /> bBox ___-- -__- Type Filter Materia _rte______- <br /> -n--:-'- <br /> ' <br /> ��� f Y �• �,D!,slance to-tne"arrest:,.Well"_- •9--,�-____-- " -\Foundat'on ------------------------ Property Line ------------------• <br /> - Rock Filled Yes ❑ No <br /> , <br /> SEEPAGE PIT Depsth___-'--------------- Diameter ----------- __' Number ----------- <br /> , <br /> Waier Table Depth ------ - -----------------Rock Size ------------------ ------ <br /> Distance t <br /> o nearest: Well ------------------------ <br /> _Foundation -------------- ----- Prop. Line ---------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------_----------------------------------- <br /> Date ---- -----------------------------] <br /> Septic Tank (Specify Requirements) -------------------- -_ - <br /> Disposal Field ISpecify�Requirements]_- -- �- <br /> `/ r <br /> --sc a � -- ------------------------------- ------------------------ _ <br /> ------- ---------- ----- <br /> -� ------------------------------------------------------------------------- <br /> 1 (Draw existing and required addition on reverse side) <br /> I hereby-certify 4hat•I have prepared this application and that the work will be done ini accordance with San Joaquin <br /> County Ordinances; StatejLaws, and Rules and Regulations of the San Joaquin Local Health District. home ow�r or Iiccn� <br /> sed agents signature certifies the following: 1` <br /> i "1 certify that in the performance of the work for which this permitis issued, { shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed Owner <br /> _ ---- <br /> --- aa <br /> t Title e WV"__ _ r2r^------- --- --------------------- <br /> (if other n owner) /- <br /> i FOR DEPARTMENT USE ONLY <br /> [ ----------------------------- --------------------_. DATE --------fit '�-- ��_ <br /> APPLICATION ACCEPTED BY ---_ __.-_ _--____________ ________ <br /> yBUILDING PERMIT ISSUED -------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS--------------- - -------------------------------------------------------------- <br /> ----------- <br /> --------------------------------------------------------------- <br /> --------------------------------------------------------------- <br /> ------ ---------- . <br /> j ------- ------------ --- <br /> ---------------------------------- ---- - <br /> Date --- - --- ---- ---- <br /> Final Inspection by. -- ------------ --/------- --------- .------------•--- -------------- ------------ <br /> SAN4JOAQUIN LOCAL HEALTH DISTRICT <br /> P u 0 1.'68 Rev. 5M <br />