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FOR OFFICE USE: <br /> . t APPLICATION FOR SANITATION PERMIT <br /> -------------------- -------------------------- Permi- <br /> t No. <br /> -�__---- <br /> {Complete in Triplicate) ,, - <br /> 1 <br /> ---------------------------- <br /> _____ __________ This Permit Expires ] Year From Date Issued Date Issued --- <br /> i <br /> 1 . <br /> Application is hereby made to the San Joaquin local Health District for a .permit to construct and install thea work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations.. <br /> u� <br /> F <br /> JOB <br /> ADDRESS/LOCA <br /> 7 � _1.�--- S �__ j P --- RR------ <br /> -----CENSUS TRACT ---� <br /> ` <br /> Ower' Name ------ 1 ------------- ------KnU_F_G _R-------------------- -------------------Phone --------------= <br /> Address -`------------------------------ -------------- -----------------------------------------------------­. City ----------------- ------------------------------------- <br /> Contractor's <br /> ----------------- -- - <br /> -- <br /> Contractor's Name ---Rim// -------------License # --------:------- Phone -, ------� <br /> Installation will serve: Residence gApartment House-E] Commercial ❑Trailer Court ❑ ' <br /> ' i <br /> i Motel ❑ Other __ ______ _ k_ 1 �� <br /> ------ _ <br /> Number flliving units rJ __ Lot Size __ ___ <br /> k ` .. <br /> Number of bedrooms ___ Garbage Grinde _ --a <br /> Character of soil to a d�pth of 3 feet: Sand Silt El ClayPeat { �� -' ----Private ❑ <br /> Water Supply: Public S; stem and name � __ - - 1 ___-_- �' � <br /> ❑ ❑ r� Sandy Loam (] Clay Loam .n <br /> Hardpan-❑ Adobe-O—Fill-Material/lL�----- If,'es, type- -------; ---------------- s _. <br /> LA/ <br /> (Plot plan, showing size of lot, locataon of system in relation to wells,;buildings, .etc. must be pl"ced on re�,rerse side.) <br /> NEW INSTALLATION. (No septic tank or seepag,,,Pit permitted if public sewer is_avail.able within 200 feet,} r r a✓� �r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size_ x_t_CZ__ ____-__ Liquid Depth <br /> { S ___ <br /> C4OC�-1-7No. Compartments <br /> Capacity __ TypeP Materi !C <br /> _ r�r ---- l" --------g- ---'---------- Foundation ----���----� - Prop. Line �.:--== -�---...----- t <br /> LEACHING UUE -- NoDist of Lines ance to near-; : Well r � f <br /> 7l j Type <br /> -- Len Length of each line---------------------------- Total, Length ----------�_.f--__------- <br /> jL �, 'D' Box ------------ T e Filter Material ---_--�--_-- Depth-•Filter.-Material ------------Distance to nearest: Well _--_�,.� /� =-Foundation—' <br /> --_- _----_--T-property Line ' , -� <br /> [. _ <br /> c��, l <br /> SEEPAGE PIT [ ,1 F Depth _--� - ` ! "'_ --- Number -----/---_ ---- 'kp' ck Filled Yes - No <br /> - Diameter <br /> l Water Table . <br /> Depth ----- =------------- -� R SFr i <br /> - - ------_--,� ock Size <br /> ✓f i I y � �j � <br /> ^fir Distance to nearesf: Well -._____�_- ------------------F'ouhdati n ': �' Line <br /> r Prop. ---------- <br /> -------------------------------------- <br /> REPAIR (Prev. Sanitation Permit# ------- i____ __,__ _ Datei_______.F____. _ �; _:____4 ) <br /> ' { l —r. 1. <br /> Septic Tank {Specify Requirements} - . F --------`-- <br /> Disposes 'Field (Specify Requirements) <br /> ` , a ¢ <br /> ----- ------------- /Art --------- i c-�T'1 _ aS f _DD �? �a-----.— <br /> T t <br /> _ —------- --------------------------- ------------ � <br /> ff <br /> (Draw existing and required addition ori reverse nide) <br /> I hereby certify that t havep ePxred-th[s-;*p-pl cation;and that the work-will} be done 6n ;accordance with San Joaquin <br /> County Ordinances, State Laws and Rules and Regulations of the San Jodqui local HealthlDistrict;`Hne owner or licen- <br /> '_ ti �.; - <br /> a sed a g'ents-signature certifies the following: f�-i '/ , it t <br /> "I certify that in t' e- erformance of the work for which this { <br /> P permit is issued,`!'shall'notl,�employ any persorf`'in such manner , <br /> as to be c a subject to Wo�kr�tpn's-Compensation laws if California." <br /> Signed _Sf r Owner , � t <br /> By ------ C�` f ' "�_ Title _ � ,a :S_... <br /> -- ---------------------- - <br /> - ----------=-------- <br /> (if her than owner} �„ <br /> FOR DEPARTMENT USE ONLY { <br /> APPLICATION ACCEPTED '(BY _ - -,----------:---_--- '`�- <br /> - DATE..-- __ - ,/-- <br /> BUILDING ERMIT ISSUED ------- ------------------------------ _ <br /> ADDITION,*COMMENTS -i ---------------------------------------- ---------- DATE ?-'' <br /> f ------ ----------------------------- ----------- <br /> ------------- fa <br /> ,l fl ------------------------------- <br /> ----------------- <br /> ______-_ _ <br /> _____ ___________ <br /> Finallnspe <br /> - - - -- -- -Date ---- <br /> - --------------- ----- <br /> �� SAN JOAQUIN LOCAL HEALTH DISTRICTy „1 <br /> ., <br /> 1-'68 Rev. 5M t <br />