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.. . . . . APPLICATION FOR SANITATION PERMIT <br /> .......:........................................... (Complete In Triplicate) Penni(No. ...77.:. 5 <br /> • •. ...... ........... ......... ... This Permit Expires ! Year From Date Issued Date Issued':.:�"°1:7�72 <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to construct and install- the work herein I <br /> described. This application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATION ................... . :° :. ° ...:.... .......�Yl�7J� `� CENSUS TRACT <br /> Owner's Name ......... 2r ......t .j/ .f ...... ../ ...... �r I <br /> ..�. . _ r .. .....Phone �.�-.� :..ltv...'�:.... <br /> Address ...... '' . .............................. ... ^ . ---- <br /> Contractor's Name ....... J: "-; r� '' . ..kicenie ..c ,�::a� �� Phone <br /> �_._.�....:..... <br /> Installation will serve: Residence�Apartment House O]Commercial[]Trailer Court <br /> ' Motel C]Other <br /> l ... <br /> Number of living units:_..1...... Number of bedrooms __a� Garbage Grinder Lot Sizeh. <br /> ` <br /> Water Supply: Public System and name `1' <br /> ..........:..Private�' Q <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam day,Loam ❑ <br /> Hardpan❑ Adobe❑ Fill Mcterial ._.._., if yes type............... ............ {l <br /> (Plot plan, showing size of-lot, location of system in relation to welts, buildings, etc. must be'.placed on reverse aide.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) ' <br /> PACKAGE TREATMENT ( ) ............. <br /> r <br /> SEPTIC TANK ;.J�.,. : .., Size............. ...................... ...... Liquid Depth <br /> .. ..� <br /> Capacity _... Type .................... Material---._........._._- •_.>No. Compartments _-- ------..... <br /> --------------- - <br /> r '- f <br /> Distance to nearest: Well" ...................................:Foundation ..--•--.............__ Prop.Llne <br /> ............ <br /> LEACHING <br /> LEACHING LINE J No. of lines ... .................. Length of each line............................ Total Length ....... <br /> 'D' Box ........... Type Filter Material ....................Depth Filter Ma 1` } --...'...................:..... !� <br /> A <br /> D€stance to nearest:Well ...:............:;:.:.,Fqundatlon .....: `..:�'.. Prroperty,Llne ................. ...... <br /> Ak 4 <br /> SEEPAGE PIT ( 9 Depth .................... Diameter _........-----.. Number .......... ................. Rock Filled Yes ❑ No <br /> Water Table Depth _........._ Rockixe t <br /> .i; ......----•---...-----•• -•...................... ..... <br /> Distance to nearest: Well "- ........Foundation <br /> -----•-----•.... <br /> ....................... _._....... ......... Prop: .., <br /> line ......... .... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ....... <br /> ' t <br /> `��• __... ...... Date .............................--=••I � <br /> Septic Tank (Specify Requirements) ................. .. ..:: ...... ...... w <br /> Disposal Field (Specify Requirements) _• �C'r'y. , -'",�✓.. t �`'.-•--- f t --_ <br /> ..... ...... .. .. . . ....................... .. .....5. ..:... ...........(Drow-existing and required addition-on-reverse aide) <br /> I hereby certify that i have prepafed�Hiis application and that the work_will "be dons► In accordance.With San Joaquin <br /> County Ordinances, Slc4 Laws,,and Rules•and Regulations of the San 3a`agirin Local Hea13k:Disrrict. Ham o mer or Iicert- <br /> sed agents signature certifles�the following: '------- -, 4"s � ' V . <br /> "I certify that in the performance of the work far which this permit is issued, I shall not'eiripfn"y any person'In such manreae <br /> as to become subject to or man's Compensation laws of California." <br /> Signed ......... i: <br /> ................................. .. Owner <br /> By <br /> ...,......�.o.... i(If ......... . .-�....... ............................................. - ttle . . ........- .... •-----. ....: _ .----- <br /> -other than-owner} <br /> FOR DEPARIKK US LY r <br /> APPLICATION ACCEPTED BY................:.................... . DATE ......3 177� <br /> BUILDI <br /> NG PERMIT ISSUED ............................ ......... _.:... ...._-... .. .. ..-.................DATE ..._............................._.....--- <br /> ADDITIDNALCOMMENTS ............................... ---...........--...---..............................................:....... ---- ........ <br /> ..........•-.............................-...........----•---••--••--•-•-•--•........--•-••-•----•-•-................................. --•--..............-......---...............--.........._.... ; <br /> ....--•...............................•--.....-..........---...................................----.............. .. .-..:.............................................----..... <br /> ............................................. ............................................................. <br /> Final Inspection by: <br /> :.. �.......Date ...... - ............ <br /> EH 13 24 1`68 Rev. � SAN JOAQUIN kOCA HEAL?D! ' ICT 8/7!t <br /> It <br />