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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Qq <br /> ---•._--.. ------- Permit No: <br /> pV - _ _- (Complete in Triplicate) <br /> -------....-_.---.1.Q.�-- Date Issued -�/-1.73 <br /> This Permit Expires 1 Year From Date Issued <br /> : <br /> Application is hereby made to the Son 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 ... -------------- G'ro `J-..... <br /> CENSUS TRACT _-.__.. ___..._.._.. <br /> Owner's Name !Xzo. S lp '--....Phone <br /> f� r� � �._ <br /> `----'-----' <br /> AddressCity <br /> Contractor's Name .. iCrL[ £�-...t.0 `C✓-- ',rGt---..�. -5.�------License # rtr-S��1-�- Phone -.'or_._-p�_.� ,.�- s� <br /> Installation will serve: Residence❑Apartment House❑ Commercial eraller Court 0 <br /> Motel [I Other ._ -----'- --------._ <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ......._.. Lot Size <br /> Water Supply: Public System and name --------------------------------.__.-.................-...................................................Private lit' <br /> Character of soil to a depth of 3 feet: Sand L] Silt[IClay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material ............ if yes,type __------ ------------------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse dde.) i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) i <br /> PACKAGE TREATMENT [ ) SEPTIC TANK Size.--------'`.---x-r����S++-..�.............._ Liquid Depth --__-,`.5...} �-.---. <br /> Capacity 1.,400-....._ Type�E.4A3T._T Materia I...GA.n.?ACfl�Jo. Compartments -._..`tea-...... <br /> f <br /> Distance to nearest: Well .....!.(QQ _..............Foundation _Lf1-_-__----_. Prop. Line .... .-......,.-.... S <br /> r . <br /> LEACHING LINE [ ] No. of Lines ...---..1-_--.-___-_ Length of each line... ..---_..__ Tota[ Length ----.. a-...._-__-.-_ V/ <br /> 'D' Box �_.. Type Filter Material ....tl-SJV,.---Depth Filter Material -----_---.� ........... _ <br /> Distance to nearest: WellIQs??-..r..._ Foundation _-lQ-�.... Property Line, --_wS.._---._..:---. <br /> SEEPAGE PIT [ ] Depth .,2S-------- Diameter AS-3....... Number _ ...../................ Rack Filed Yes jyiNo Cl <br /> � / 1 <br /> Water Table Depth ___1-1 �_..---'---'------.............. <br /> Rock Size <br /> Distance to nearesti Wel[ ..../119 --LO--....---- Prop. Line ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..._................_._................-- Date ..-._-..-------------------------) <br /> Septic Tank (Specify Requirements) ....................._..........._.......................................___.--_-__...._-_---_____.._-.-„._...._._..�..._�--. <br /> Disposal Field (Specify Requirements) ._.....-..........-......_--_.........................................................__..-_____....-___..._....---..-.. - <br /> ............................................... - -- <br /> --....:. __....-...._..----._....-_..---.....-•-• ------._...- -----.-_.-.•-------..._.----....-..._...--- •- <br /> ...............................-- .............. -' ---'--' -------------------------------._....-------------................................. ------------------------------- . .......... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1.have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that i the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becom u ect to o Co cation laws of California.” <br /> Signed ...... ..... ...... <br /> ._...--- - _lc.eR�- �.....-...._ Owner <br /> By.......... - ---- 4he'_.. .. - - ' e-- �----( LJ Title _ ct -�............... - - <br /> (If other than o <br /> FOR D PART E ONLY <br /> APPLICATION ACCEPTED B --- - _-- ------- -- --- ...... _ - _ DATE .../O. ' -- ---.-- 1 <br /> BUILDING PERMIT ISSUED ..�....... .. .............'--........... <br /> -....DATE ...'-•---------.......--..........— <br /> ADDITIONAL COMMENTS ... . ..Z - �i-Ori....... ------------------- <br /> ---'--...... <br /> ..........................._ - -- - - .-.. .-.. . .-. <br /> ._--- .. . . L. .. <br /> Final Inspection b -----.. ... -'----'-'-' --__. .---'-- -- -----i._._- -----...� .............-Date _.-_LC� .- -'--..--... 1 <br /> SAN JOA21JIN L L HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. SM �� <br />