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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -. _'_7v- Permit No. <br /> (Complete in Triplicate) <br /> Date Issued __ _ . --7h <br /> -- --------------_------_------------_ This Permit Expires ] Year From Date 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 comp 'ance with County Ordinance No. 549,and existing Rules and Regulations: <br /> (?�4 <br /> (( CENSUS TRACT ----------------------.---- <br /> JOB ADDRESSILOCATIO --------------------- �- ---- - -- -- --- - - -1----- 7 � , <br /> Owner's Name .>(i��.- / ----------------} ----- - Phone <br /> -------------- -- --- --- -- -- <br /> -G --- ------- <br /> City ---------------------------------------------- <br /> Contractor's <br /> -------------------- ----- ------ <br /> ------------------------------ <br /> Contractor's Name ------- ----- -- - --,---------- 7 -------------------------.License �------ Phone .7694 -�P- -- i <br /> Installation will serve: _ _Residen'ce[]Apartment House❑"Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other ------r�-------- -------------------------- -- - •• <br /> Number of living units:.-.-- ----- Number of bedrooms ---7-'-:Gdrboge Gri deter j--_---�_ Lot Size ___�V---------------- ----------- <br /> Water Supply: Public System and name ---------------y ----- = 4 ----------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'E] Silt o Clay E]— Peat❑", Sancl 16am ❑ Clay Loam <br /> Hardpan ❑ AdobeFill-Material ------------If yes;type ---------------------------- � <br /> (Pl'ot plan, showing size of lot, location of system in relation to'wells,-buildings etc~must be placed on reverse side.) /NEW INSTALLATION:' (No septic tank or seepage pit permitted if public sewer is available'within 200 feet,) pW <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------- --------------_.--------_-.------------1 Liquid <br /> k <br /> Depth ------ --- ------------ <br /> ----_---_---_.------ <br /> Ca acitY --- ---- -- - Type -------------------- Material---------------------- No. Compartments -A---y---------- <br /> Distance <br /> to nearest: Well --------------------�--- =----Foundati� --------------------- Prop. Line ---te_.�-_-_....._ <br /> LEACHIId LI E No.,of,Lees -------I---------- ---- Length of each line----.3S-------------- Total Length11-_-----, - _-----.-..---- <br /> J 'D' Box --__J---- Type Filter Material ---- __-_Depth Filter Mbterial ----- �cr�--_----------f.--.---.-. <br /> istance to nearest: Well __._- -_ "__ __ Foundation ------- Property Line ------- -- ----------- <br /> '. Yes No <br /> ❑E GEPIT �epth ---°--- Diameter ---3 -------- Number ------ --- --- Rack Filled <br /> Water Table Dept ---------- --------------- ------------I-------Rock Size ------ ------------------------- <br /> Distance <br /> ----- - ------------ <br /> Distance to nearest: Well -------------------Foundation-------- f0__-- Pro{. Line ------`--_ ------- <br />/I�NPAIR/ADDIIT40N(Prey. Sanitation Permit# _________-.-`�------- ---------------- Date --------------------- <br /> - ----------ptic Tank (Specify Requirements) ------ -- ---- ----------� ------ ---------- ----------------- <br /> ------------------ <br /> 1 <br /> Disposal Field (Specify Requirements) <br /> ----- --------- - <br /> t <br /> ___ ----•----------------------------------------- -------------------- <br /> (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 of the San Joaquin Local Health District. Horne 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 become subject to Workman's Compensation laws of California." <br /> Signed ------- �-�- —-------- -------------- <br /> " :--_ Owner <br /> Title I <br /> -- ------------------ <br /> BY ----------- -- ------ ------- --- ------ . ------------ - <br /> (If other owner) <br /> '` FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPT D ___-_- 4 �y <br /> ` DATE ------------------ <br /> BUILDING PERMIT ISSUED - ------------ =---- '------ - 4 --------------------------------------DATE -------------------- ---------------------- <br /> -------------------- <br />'. ADDITIONAL COMMENT ---------- ------------------------------------------------------- <br /> - -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------- ------------------------------------------------------------------------------------------------------------------------- ---------------------------- <br /> ------------------ <br /> -------------------------- <br /> --- ---------Y --- - -------------------- ------------------------------ <br /> --------- <br /> ---------------------------- <br /> Final Inspection b ( ��L�----�--- ---- - -------------- --------- --�---- -------------- ---------- --- ---.Date ----- -= <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> E. H. 9 1-'68 Rev. 5M <br />