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FOR OFFICE USE: , <br /> I� APPLICATION FOR SANITATION <br /> �Lul_ Permit No. 7 5 <br /> (Complete in Triplicate) �c�' --'• ' <br /> ., l <br /> r` Date Issued ��_.". _•"7� <br /> .......... ._ . ____ This Permit Expires 1 Year From Do 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. and existing Rules and Regulations: <br /> 60y <br /> JOB ADDRESS/LOCATI __ �z._. CJ'----"__....��O�CENSUS TRACT <br /> r >%z-,� -- ---------- �� <br /> .- <br /> Owner's Name .Q .-, 1 Phone -------?- <br /> Address ----------- '" —---------------- ......I_, City r - ---I P_e7.!y....---- ------------ -•--•-...... -7-- <br /> Contractor's Name � �_ s..fA-e-les-/ .'1--c'.� "-----License # ---- ------ Phone �'��(D'�`b•�l` <br /> Installation will serve: Residence XApartment House Commercial❑Trailer Court :❑ <br /> Motel ❑Other ................... <br /> / - `-�`— <br /> Number of living units:....__ __._. Number of bedrooms .... <br /> .------Garbo a Grinder ------------jot Size __________________________ <br /> Water Supply: Public System and name ----------------------- ............ _.._-..._..._-.----------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ 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 side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ II i Size-------------------________________________--.- Liquid Depth --------------.________.__ <br /> Capacity --- --------_----i Type ---------------_-- Material------------------ --- No. Compartments .........-............ <br /> Distance to nearest: Well ---`------- ---------------------Foundation ___"____._ ----------- Prop. Line -_-----__-.-___-___--_ <br /> LEACHING LINENo. of Lines ............. _ � d <br /> [ ] .....-.�Lengtl�of eachllne____________________________ Total Length .__.._.__._ <br /> 'D' Box ----------- Type Filter Material ____________________Depth Filter Material __.____-_--..._.._................_........ <br /> Distance,to nearest: Well �.................�.__._ Foundation ------------------------ Property Line <br /> SEEPAGE PIT [ ' Depth ......... Diameter --------_____--- Numbe ( _-.___-- Rock Filled Yes Q No ;fl . <br /> Water Table Depth ........................:........-..............Rock Size .............................. <br /> Distance to nearest: Well ..------'--------.- .................'__Foundation ____________________ Prop. Line ...._-_-_-.__-.__-_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -_.__.__.________'.-___.�___---------------- Date _.__-____---__---.-._.---_____.___) <br /> Septic Tank (Specify Requirements) -.-... ... <br /> x�`"" --` <br /> J - ------------------ <br /> Disposal <br /> - - <br /> Dispo�sa/l Field ( ecify`R uirements) --- <br /> 4 <br /> -__ <br /> ---- -- `_- "-- 1 ----------------------•---• ------ <br /> cc <br /> -------------- --- - '�--- -- - ..-- - -- ----- _ �-- -- ---------------------- <br /> - <br /> (Draw existing Tod req red addition on reverse side) <br /> I hereby certify.that I have prepared this application and that the work will be done in accordance with Son 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 /> "I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in such manner <br /> as to beco``mme�e suble Workman's Com eeensation laws of California." <br /> 5.� <br /> Signed -�--- -�=�+1 - A.�.(�4��.-�'------- -*L..S.. ----- QwFief <br /> - <br /> gY .... -.... ------............ •---- - - - -� -----• Title �x.,�/_.. <br /> (If other than owner) <br /> FO EPARTMENT PSE ONLY <br /> 4`APPLICATION ACCEPTED.BY .............. DATE ..-- ___. -2-.------_---- ........... <br /> BUILDING PERMIT ISSUED -------------•-------------------------------------- ......`=•-------•-------DATE --------_-•--•---- : -------------------- <br /> ADDITIONAL-COMMENTS ------------------"•----- - ._..-..._..-_.... <br /> --"--------•--------- -----•---•---------- -•------- ----------------- •------------------------------------------------------------------------------- <br /> ------------------------------------- <br /> Fina! Inspection by: - ------------------•------------Date [-- <br /> SAN JOAQUIN/L CAL HEALTH DISTRICT <br /> E. H,'9 1-'68 Rev. SM'" IMIPW <br /> te <br />