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7 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. <br /> --- ---------------------------------- (Complete in Triplicate) <br /> Date Issued __. ____-- ---•---• <br /> ----------- This Permit Expires 1 Year From Date Issued <br /> Dunt finance No. 549 and existing Rules and Regulations: <br /> ' atian is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> Application <br /> This appl;cation ;s made in compliance with Y � <br /> ......CENSUS TRACT __ :t�_T------------- <br /> JOB ADORES LOC-AT.ION _ Phone -------------- <br /> - -- -------- r,�rrti - <br /> --- -- - <br /> Owner's Name .J <br /> --------- ---- <br /> G <br /> ------- ------ <br /> Address '1 <br /> r d Phone <br /> - -,"�=- - G-r-L�-��- -- ----- -- License # -------- --- <br /> Contractor's Name -_ ------ Commercial []Trailer Court `❑ <br /> Installation will serve: <br /> Residence Ae <br /> /Apartment House <br /> Motel ❑Other --------------------- <br /> f �---Garbage Grinder _----__---- Lot Size ----------------------------------- <br /> ---------------- -- ------- ----�_ <br /> Number of living units:_---a_----- Number of bedrooms __-____---- ------ --Private [ <br /> - -------- <br /> ---- - ----- <br /> ------------------ -- <br /> Water Supply: Public System an name -------------------------------- --- <br /> Peat❑- Sandy Loam ❑ Clay Loam ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ <br /> Hardpan <br /> Adobe E] Fill Material ------------ If Yes,type ----- --------------------- <br /> on <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. <br /> whin 200f eet l reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit perm;tied if/vv <br /> b�c sewer ti <br /> - ----�----- --- L;quid Depth --.-�'---------------•SEPTIC TANK Size__ ----X- <br /> PACKAGE TREATMENT [ I k �No. Compartments ---�--- <br /> �_ T e �- -- Material- P <br /> Capacity ��--- - YP ,. r <br /> :�fi------------------Foundation ---1G------- ---- Prop. Line ----'��----------- :---• <br /> Distance to ne ar st: Well ------------ <br /> LEACHING LINE [�No. of Lines - -__-- <br /> ------ Length of each line-.--------j--�- Total Length�---- `--• <br /> p -- ... <br /> ---.... <br /> 5' 1 to a#erral ------1-= ------ -----�r--,- <br /> D' Box ____ _-._-- Type Filter Material _._---.- ---=-Depth�F;l <br /> Distance to nearest: Well ---- __ . _ Foundation p Lin e __ .-_ -•------ <br /> ' / � _. .. ---- - ----- Property <br /> ,� ;- :`• Number -------- -- --- 'Z Rock Filled Yes No 10 <br /> SEEPAGENT [ p Diameter --__ ...... <br /> , <br /> Depth - --- ---- l <br /> ���--`----`---------Rock Size --���--�-rx-=-�'------ - <br /> Water Table Depth ----------------- ��f✓' <br /> ( Foundation ------V�-KProp. Line ..------- <br /> Distance to nearest: Well ----- Cc---- <br /> Date <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- --------------- --------- <br /> Septic Tank (Specify Requirements -------------------- <br /> ---------------------- <br /> ------------ - <br /> ------------ ------------------------------- <br /> --------------------------- <br /> ------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements ------------- - --_ <br /> - ---------------------------- <br /> -------------------------------------------------------------------------------------------------------------- <br /> --- - (Draw existing and required addition on reverse side) <br /> ne it, <br /> ! hereby certify that 1 have prepared this application and <br /> that <br /> of the San Joaquin LocaloHealth D strctnHomece towne or liveh Son n- <br /> County Ordinances, State Laws, and Rules and Regulations <br /> sed agents signature certifies the following: -permit is issued, 1 shall not employ any person in such manner <br /> "I certify that in the performance of the work for which this <br /> as to become subi to Work an's C pensation laws of California." <br /> Owner <br /> Signed - Z_�? � <br /> r 4 <br /> --:��-_----�--- <br /> �°-- ------- ------- Title ----- ---Vii,--: - -.__L�------ -- -- ------ ----- <br /> (I other than owner) <br /> ` F R DEPARTMENT USE ONLY <br /> �� ------- <br /> DATE ---- -----------� �- <br /> - DATE -------------------- <br /> APPLICATION ACCEPTED BY _. _ _ -- -���-'��--- ---------------------- <br /> ----------------------------- ------------- - <br /> PERMIT ISSUED --------------------------------------------------- <br /> ----- -- ------ -- ----- ------ ------------- -------•----- ---------- <br /> ADDITIONAL COMMENTS ------------------------ - - ------- <br /> ------------------------------------------------ <br /> -- -------------- --- ------ ---- ------ ---------------Date-24-` �-- ---- - <br /> ---------------------------------- --- - - ------------------------ <br /> Final Inspection by: -- - �rv�� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />