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FOR OFFICE c,sl:: � . <br /> .... APPLICATION FOR SANITATION PERMIT ��� <br /> fComplete In Triplicate) Permit No. .. ......-..._----.- <br /> This Permit Expires ! Year From Date Issued Date Issued ..3J � <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 Ora, ante No. 519 and existing Rules and Regulations: <br /> J08 ADDRESS/LOCATION ....z .. . <br /> �F .-....... CENSUS TRACT ....................:..... <br /> Owner's Name ...... •�:.._... -.:. Phone ............... <br /> ,__ <br /> Address ! - _._.. City <br /> � ......................... --- <br /> _ r <br /> Contractor's Name ..- ,. t,�C.� Y 6 _ ,d_; dk. .License ,# .J/ , .... Phone �y� n t7 -- <br /> Installation will serve: Residence;) °Apartment House 0 Commercial❑Trailer�Court fl <br /> r Motel.❑Other --------- ! <br /> Number of living units:..... ..... Number of be roo s __-.2.._,_Garba a Grinder _. Lot Size _____ __ ________________________ <br /> - _ <br /> Water Supply:.Public System and name ----$1411ak.-... . 1 <br /> Charade i of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat E] Sandy loam❑ Clay Loam 0 . Y <br /> • d <br /> �Nardpg9.0 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 /> IVEW;INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACICAGE TREATMENT [ 3 SEPTIC TANICe.--•--f-__•............................ :...... Liquid .Depth ...................... <br /> I Capacity .::.-.--•-- ------•- Type ...........•---•.... Material.. •---•............1 No. Compartments. ----------•-----••---• x <br /> P <br /> - x <br /> ' Distance to nearest: Well -------------------•-----..._-__ ---Foundation ....................... Prop. Line .._............._..... <br /> P <br /> LEACHING LINT: No. of Lines .._.. .-.. '...._ Lengthof each l ne.. ...`... Total Length _,f..............S <br /> D' Box -`-`�'.. Type Filter'Materiol ...Depth `Filter Material (y/69l r <br /> ' -V_ - � F O. ...�i•••.................�_............Distance to nearest: Well . A:4;C_ Foundation•i_�_,/Z�F_..........� Property Line <br /> i • .., * ' �. ...{ ...... <br /> SEEPAGE PIT ° Depth g0Aiameter ` Number I:....-} Rock Filled Yea No:(D i <br /> y it <br /> 5 � Water Mable .Depth �/�/_. r- Rack-Size . ............... <br /> I <br /> Distance to nearest: Well foundation ---1.1le..--.-- Prop: tins : .__:_••----------5 <br /> �- <br /> REPAIR/ADDITION(Prey. Sanitation. Permit# .................................... ...... Date_-t-_.___._.____._............ <br /> ) <br /> i <br /> Septic Tank (Specify Requirements)�.----.................... .. ........... --• •----------------..... ......._l�•.�... ......:...... ...... <br /> _ 4 r <br /> Disposal Field_j5p'ecify Require . nts} .-•_-_-_ -- --- <br /> 1C .. �._... -•-- . ............ ..... .......... _ <br /> ' (Draw existing and required addition on reverse side} ; <br /> I hereby certify that I have prepared this applicatibn and that the work will'be done w accordance with San Joaquin <br /> County Ordinances, State Laws, attd Regula"gons of the San Joaquin7Lecal Health District. Home owner or licen- <br /> sed agent's signature certifies the(61(owing; <br /> "1 certify that in the performance of the work for which this permit is issued, .1 sal not,e'O'nploy any person in such.manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ...•-`---.......-- ------------- --••--. Owner }. <br /> ----- ---- <br /> i <br /> BY `------• T... Title ------- <br /> (If other than owner) <br /> FOR DEPARTMENT-USE-ONLY— <br /> APPLICATION <br /> EPARTMENTi1SE-ONLY—AfPliCATION ACCPlED BY -- --- --------- .,_-• --. - v � . DATE .... .. :-=--- <br /> 81111 D1NG 'PERMIT ISSUED .------ - DATE <br /> ADDITIONAL COMMENTS .......... ------- ------------ ----f = = <br /> .�. ._ _ a _r .� - - -•--- <br /> --------------------.................................................................................:�......_.._..........-_....._.._........_................•-...- <br /> ........------------..------------..................................:................................................................................�....--------------------------_---------------------- <br /> -----------------------------------....... .. ._.. ---.------------.........................-.-..._.....-.--- ..._....................,...,.,.... <br /> Final Inspection by- ------ --- ------ ----­ ------------------Date . ..C� . .. <br /> EH 13 24 1-68 Rev. � SAN JOAQUIN LOCAL HEALTH DISTRICT � $/7h 3g <br />