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X fJK VrrlLt: Mt. <br /> APPLICATION FOR SANITATION PERMIT <br /> ............. <br /> (Complete In Triplicate) Permit No. ._7,?•r_•..../S- <br /> ........... This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin.Locof 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 /> f <br /> JOB ADDRESS/L0C TION .........�,�'��`-�"�� ..... .�f1�'�G ... JJ`` <br /> �°+ x t�,...J�./iy..-CENSUS TRACT _......................... <br /> Owners Name ........ om- -_-._.... <br /> - .............................................•......_Phone r�.l.C�-...:Az2�..- <br /> Address ..._._...... - ........�.,�.G../+I�Y� _.�......... G <br /> ty <br /> Contractor's Name ------- -------------- <br /> �L GSA <br /> ............................... <br /> ...............•-----......... <br /> /q.j. ,---, ----- <br /> - ------------------------------License ty- Phone o�'3__.�`.:�r�..�� <br /> Installation will serve: ' Residence 'Apartment House Commercial❑Trailer Court 0 <br /> 1 - <br /> Motel[]Other---------------------------------•-- ----- <br /> Number of living units--f-_.-__- Number of bedrooms __S Grinder .----------- lot Size --__-,Z,�� ---�----- <br /> Water Se3pply: Public System and name _---_•-----............................................ <br /> ---••------•-----••-------•----------•-•-------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt C7 , Clay [] Peat❑ Sandy Loam;1' Clay Loam ❑ <br /> �! Hardpan ❑ Adobe Fill Material <br /> '❑ ............ if yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted 4f public ewer is av a lable within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK �� <br /> Size.'r .�f ..r.,� ----- Liquid Depth _.-� -----. Ut <br /> Capacity 1- 4-�----• Type C_'�_ G-_�' Material--- -_-- No Compartments ..c-._ - _ e <br /> -----• <br /> Distance to nearest: Well ._ ` <br /> = - Foundation _...-•-•.-•-_. Prop. Line .. ........0 <br /> LEACHING LINE [ No. of Lines -. -- - -•-----_- Length of each line.__.._9%C>' .-_---- . Total Length ...�?Z. .......... <br /> 'D' Box , Type Filter Material / <br /> epth Filter Material ,� ... <br /> Distance to nearest: Well .......... Foundation o�7........... Property Line . <br /> SEEPAGE P1TNumber ..... Rock Filled Yes ❑ No ❑ <br /> Depth ..............• -- Diameter <br /> Water Table Depth .-----------------------------------------------Rock Size ................................ i <br /> Distance to nearest: Well ----------------------- __----_ Foundation ..__..--...__....... Prop. Line __....__-__---....---� <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date .............._...._ ••1 -� <br /> Septic Tank (Specify Requirements) ................... ....... . ... <br /> Disposal Field (Specify Requirements) __________ _ <br /> ................ -9 <br /> -----•---------- ----­--------- __ _ � <br /> ------------•-•----(Draw existing and --reverse------•------sid---e--l-•............................••----..._.......--------_--- <br /> - <br /> 1 hereby certify that I have prepared this application and that red addition on t the work will be dome in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or litew <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to ork �st*' on lawsof California."Signed .__. ,_. -------,---- Owner <br /> BY - - •-- - --- ------- ---------- Title - ----.------.........................•-----•----•-•---- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... <br /> DATE <br /> BUILDING PERMIT ISSUED --- _ ---....---•-• <br /> -----------------••--------••-• - -----------------------DATE --------------- ---- -- <br /> ADDITIONAL COMMENTS --------------- - ------- ------------�-'--- <br /> -------------------------------------------------- -- ---------------------- <br /> ------------------------------------------------------------ ••-------- ...............................-................---------•--------- <br /> ..---.----•-•....... - - <br /> .............................. --•-----•----------- •--------- <br /> Final Inspection 6y ......_ -.- <br /> ------ ---- --------------•---------.._.....................------- - --- -•--- ---------._...,_.Date ..--------------• <br /> EH 13 24 1-68 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />