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OFFICE USE <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate]'if . 171 <br /> Permit No. -... -.�� <br /> Y <br /> S <br /> /6-, <br /> . a <br /> This Permit Expires 1 Year From date!#sued <br /> y <br /> Application is hereby made to.the�San Joaquin Local Health District for a permit to construct.and instalL the work hereln <br /> ' desci ibed. This'•apphcation is made in compliance wiTh County Ordinance 'No. 549 and ezistmg= Rules a`nd Regula+�bres: <br /> z; .. 3,. �, 1.1. <. ':�� - -;_e8 tri_ S_. <br /> SOB ADDRESS/LOCATION -.i//EJ�G� / U1JG C. �f F'L�f�fJG� .... SUS _ -- <br /> _ w - i� <br /> Owner's Name ff'4'��'---. --- 1 .� �J fSCii�J'G ._ Phone�'�,�./-- - <br /> jr -E - <br /> Address .ry` 1.��.. rr�- r rE�:� ,<�i:?.. City ✓G`fi� ..L. i� � - <br /> Contractor's.Name; ---. L+�'4Ji'J��Sj... - --' License # ....---- Phone <br /> Licens ---------- <br /> Installation <br /> --' ---Installation will serve: Residence eApartment House'❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ------- - - ----- - " ----- <br /> Number of livin units:--'__- _'Y_.- Number <br /> a . <br /> g of bedrooms -__Ga�bgge Grinder .___ _.... Lot SizeG'CU O <br /> Water Supply: Public System and name. -' - ------------ ------------------- -- ------- --------Private [ ' <br /> j.. . .; <br /> Character of soil' to a depthof 3 feet: Sand '[ Silt ❑ Cray ❑ Peat ❑ Sandy foam 151Clay Loam ❑ <br /> r Hardpan r-] Adobe [�l Fill Materia }f yes type .. <br /> (Plot pfan, S4Iowing size of lot, location of system in relation to wells, buildings, ,etc. must he placed on reverse side.)" <br /> NEW INSTALLATION: (No seepage p se tic tank orit permitted if public sewer is E�ravailable.within 200 feet,], U v <br /> P 'T <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] Size... .,,.. - _�f' .:....... ....... Liquid Dept, .. .. ------ ----- <br /> :r - , ( �JU <br /> :r-s1O ype _-_-- Material... No. Compartments � <br /> ---- <br /> Capacity <br /> Distance to nearest: Well ------------------------.---•Foundation ----------- __ Prop. Line <br /> LEACHING LINE [ ] No. of Lines __T_�Hs: - Length of each line.��-"��--------------- -- Total Length --2�0- <br /> 'D' Box -------------- .Type Filter Material __.......--......_Depth Filter Materia) <br /> Distance #o nearest: Well -_ _...77 --- Foundation ..--.------------ -Property Line -------------- ------5 <br /> . .. <br /> SEEPAGE PIT ------ <br /> Depth Diameter "-- -_"' Numbe,- <br /> ?_.. Rock Filled Yes ❑ No 0 <br /> Water Table Depth .. . -- _.. ------------ ----------Rock Size - <br /> Distance to nearest: Well ....__.-- -- . .Foundation -----...-.----,-_-- Prop. Line ------------- ------ <br /> :. <br /> REPAIR/ADDITION{Prey. Sanitation Permit # ------ ---- - <br /> - --- - Date .....--- ---- ... , <br /> �- --------- <br /> ---------------- '--..._7ti-'--- <br /> -----...---- <br /> Septic`Tank [Specify Requirements) --- - :. -. -- <br /> :; <br /> --------------- <br /> ----- --Disposal Field {Specify Requirements) _.-..- �_ <br /> ---- <br /> - ------ .. ---- <br /> " " <br /> --------------- <br /> - - ".. .. - <br /> .. <br /> -- --- (Draw existing and required addition on reverse side)e work ' <br /> ,: � <br /> �I hereby certify <br /> that I have prepared this app Re!oin and Regulations <br /> hat t1h ofthe San laaquirti LocaloHedlth Distr�dCtnHome!ce to�vner or Ih Son ces <br /> County ordinances, Stat e Laws, andfRules an g ' <br /> sed agents signature certifies the follow ing`` p y person in such mann <br /> "I certify that in the perfOrrrtan of the work for­which-this permit is issued, I shall not em to any p € <br /> las to beco��suect to yv k nn's Compensation laws of California." , ) <br /> Owner <br /> Signed 7 <br /> - _- _ Title .. ............. ..... - ----- <br /> ------------------------- <br /> ------------------------ --- <br /> {4f other than owner} . <br /> FOR DEPARTMENT USE,ONLY <br /> Zc ! <br /> - -- / _. --'--------------- <br /> r"' +( .; �_ , DATE .__..,. ....- <br /> -- -----'----------- r, ......t <br /> APPLICATION ACCEPTED BY . �- ------t-----------' - " " " DATE ... <br /> BUILDiNG PERMIT ISSUED .:- ------ --•---' -- '-' - - -- <br /> ---- <br /> # ADDITIONAL COMMENTS` _..........-----.....-- -------------------- --- - ....._.........--..... ..... .. -- '- -'---- ' - ';------- <br /> - <br /> ----- ---- --- - <br /> - -' <br /> _ <br /> w <br /> - --- i Date .....- .. .... ." . .. <br /> final Inspection bSAN JOAQUIN LOCAL IEA4TH DISTRICT . <br /> - <br /> E. H, 9' 1-'68 Rev.;5M <br />