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' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. 0f_=_Z7.._ <br /> r (Complete in Triplicate) <br /> ' - - Date Issued <br /> This Permit Expires 1 Year From Dale Issued <br /> ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> desvibed. This application is made in compliancewith-County Ordinance 549 and exisiing'Rules and Regulations: <br /> JOB ADDRESS/LOCATION �... ........ �~� J ---- -- --.- --: -CENSUS TRACT ... <br /> gyRp__ W©l i ... �,L ._... . ........ <br /> ' Owner's Name ....--l.Xl�±'L� ---� .. ......... ... . .........._ ne • <br /> �..... - ...... <br /> Address --........------"--- --- ------ .. ............. City ,.�-...._ <br /> -------- ---^ <br /> ' Contractor's Name -_- License# --.-.--- --- -- Phone 9.A-W------- <br /> Installation will serve: Residence❑Apartment House-E] Commercial.{]Trailer Court �] <br /> ' 1 Motel ❑Other .... ................:................ <br /> Number of living units:-r_ .... Number of bedrooms _- _ _.-__ i ( Lot Size,- - <br /> ---- <br /> WaterSu I Publics stem and name -_.-_-"___....-......- �-Garbage Grinder,_.`..-..._"- �' ' { _Private <br /> 1y,.► , <br /> PPY Y_ .i-...- t u . r �. <br /> t Character of soil to a depthh"o"f,3 feet: -Sand❑ (Silt❑ Clay-ID—Peat❑t Sand; Loam ❑ h y am,❑ <br /> -r - _ -Hardpan-E] AdobeX'Fill Maferia`I"".-.:."'If yes,type ............................ <br /> ' <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;I [No septic tankibseepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANKi I Size_....1...................-_-----"-.. ........ Liquid Depth -------..-----...----.----- C <br /> ' c.Lt <br /> i Capacity ---.----------IType .............._.... Material----------._...__:No:"Comparimenis _.............. \ <br /> I Distance to nearest: Well ------------------------!_....... Foundation - _4_Prop. Line ...................... <br /> ' LEACHING LINE [ ]' No. of Lines ------------------------ yLength of each line..............._.----------- Total Length ........................ <br /> .... <br /> 'D' Box -_ -------- Type Filter Material.--------------------Depth Filter Material ------------..............-.-------......... <br /> ' _ Property Line <br /> Distance To nearest: Well .--."�._..._?...,�-`' foundation ---------------_------- <br /> ' SEEPAGE PIT [ ] Depth & .._. ..... Diameter ..._.......Number -------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table-Depth f -...Rock Size ............................_.P <br /> T : . <br /> Distance to nearest: Well ............................. ..........Foundation .................... Pro Line ...................... <br /> ' REPAIR/ADDITION(Priv. Sanitation Permit# ..............�------_.---------.------:.--- Date __ ---------------------------- <br /> t <br /> Septic Tank (Specify Requirements)_----------_- -.: .. ......11---- .. -- - - �- -_...... <br /> ' <br /> Disposal Field (Specify Requirements) ................ 1 11 <br /> ti- -..._ - _-.......... _.-.. - ---........ - ••-'f"1 sS .............._....X3 ..... 7 � <br /> ....... <br /> I (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 Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations ;f the San Joaquin Local Health District. Home owner or licen. <br /> ' sed agents signature certifies the following: <br /> "I certifyi9at in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California:< <br /> ' Sig0.ned ............. . ........ ... ... -- - Owner <br /> ( Title =........ ............................... <br /> By ........ - - - - ------------- ------- -- <br /> ! ` other n owner) <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION-ACCEPTED BY .---.__ ----------------Cf.%Pl------------------------- ---------------------z_ DATE....3- -1-- .b.Q...._.--------- <br /> BUILDING PERMIT ISSUED ---- --------- ° . -- . ---------------------- ..._....--------- --.- --------------DATE ----- ----_--------------.---- ------ <br /> -' ------------............. ........................................^.............- ...._..... <br /> ' ADDITIONALCOMMENTS...- "----. .................. . .---- <br /> - - -- - - - - -- - :- - ----- -- - " ---------- <br /> ---------­----------- <br /> .._ .____.......................... .. <br /> " _-_ <br /> 2°_:_ z�2Vpti --------------------------------------- - - .._.-... .Date .. __.?... ..6 _-_1.-_... <br /> Final Inspection by: .................. .. . <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />