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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> �;pU ra-r�.�7f------ - <br /> - (Complete in Triplicate) Permit No. _. s�7/ <br /> AThis Permit Expires 1 Year From Date Issued nate Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __ / <br /> f _Ae - CENSUS TRACT -,- <br /> Owner's Name - -- - -V,/------4,gno ofd, <br /> �'f�l - - -Phone._..- <br /> Address --------•-------•--- --- <br /> � "�� / lei- -----------------------­--- <br /> 0------------------------------ city U1. /�°� <br /> Contractor's Name .- _ J_ ---- ---- <br /> ------ ------ --- -- --License #/��,owt__ Phone <br /> Installation will serve: Residence;g Apartment House❑ Commercial ❑Trailer Court P❑ <br /> Motel ❑Other ----" <br /> ------------------------------------ <br /> Number of living units:___,._----- Number of bedrooms __-1 <br /> _____Garbage Grinder�GLot Size _ - '.___ <br /> 1 S and name <br /> PP Y� Public stem Y <br /> Character of soil to a depth of 3 feet: <br /> Water Su Sand❑ Silt❑ 1vla _Private ❑ <br /> Y ❑ Peat E] Sandy Loam .0 Clay Loam <br /> Hardpan El Adobe '` Fill Material ------------- <br /> If yes, t a <br /> (Plot plan, showing size of lot, location of system in relatioi to wells, buildings, -etc} must be placed on reverse side.] <br /> NEW INSTALLATION: (No.septic tank or seepage _ i F <br /> pit permitted if public sewer is available within 20d. feet,) tv <br /> PACKAGE TREATMENT <br /> CapacitysEPTIC TANK Size___- ' _ _' Li uid Depth -_-----_ <br /> YP5191A- ""4e Mater!al(7--awle✓o---- No. Compcirtinents �--- " <br /> Distance to nearest: Well ____________ _ _ __ Foundation` <br /> '"=' Prop. Line-_--- <br /> LEACHING LINE L No. of Lines _._ g , <br /> --��"---------__"--_ Length of each line__. <br /> —s <br /> �� Total Length ----------- <br /> 'D' ,Boreal- Type Filter Materia l/ /9Depth-Filter Material ---------------------------------- <br /> Distance <br /> "_-_ <br /> I j.. ' <br /> Distance to"nearesfi: Well _.__�^-�"' _" Foundatiori , <br /> SEEPAGE PIT ,9 > ��-------------- Property Wne _t2-------------- -- , <br /> (}� Depth "-__------ Diameter <br /> , ------ Number ____Z-- ----------- Rock Filled Yes No <br /> Water Table Depth <br /> -------� � ---___•Rock Size/ .. 1 ' <br /> ------------"---- <br /> Distance to nearest: Well -------------------------------------Foundation --_ Prop. Line _.__ ....s _ <br /> -'-•��--- <br /> �f <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ______________" <br /> - s' <br /> ------- --------- -'----- --- Date --- ------_-=-=----- I y <br /> Septic Tank (Specify Requirements) t <br /> -------------------- { <br /> Disposal Field (Specify Requirements) __ "" <br /> ------------------------------------------------------------ <br /> ----------------------------- <br /> ---------- --------- ----------------------------------------- <br /> ----------------------------- ----------------- ----------- --------------------------- <br /> (Draw existing and required 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 Joa grin ; <br /> Couiity Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner ori cen- <br /> sed-agents signature certifies the following: <br /> "I`certify that in the performance of the work for which this permit is issued, I shall not employ an <br /> asJo become subject to Workman's Compensation laws-of California." P y Y Person in such manner <br /> Signed ---- ------- <br /> ----- ---- - -- ---- -------- ------ ' <br /> --- --------------------------- <br /> Owner <br /> BY'- -- ----- �------ -- --- --- ----��--- ------------------------------ <br /> : Title ---- -------- -------- -------- ------- <br /> ----- <br /> (If other n owner) �-- <br /> ' I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIADDD ONOERMIT SSUEDBY----- 7---------- <br /> DATE ------ T j a� <br /> 17/--------------- <br /> BUILDING <br /> COMMENTS .p.l- -'-�r�k -----4- --------- <br /> ADDITIONAL <br /> ---- _. - DATE <br /> --------------------------------- <br /> ---------------------------------------------- _ <br /> ---- -------------------------------------------------------------------------------------------------- --------- <br /> ---9- ------------ ---------------------------------------------- <br /> - <br /> ------------------ --- ------- - <br /> Inspection by: <br /> - ------- ---- <br /> - <br /> --------------- --------- -------------- <br /> ------ ------ -------- -------- ------.Date ----------------�------- <br /> Final ------- - ------- <br /> SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> L. <br />