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FOR OFFICE USE: r: APPLICATION FOR SANITATION PERMIT <br />Permit No: <br />'= (Complete in Triplicate) <br />-------------- -------------I ------------- <br />Dote Issued <br />t This Permit Expires 1 Year From Date Issued ; <br />--------------------------------------------------------- <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 compliancewith Cni,ntv.0rdinance No. 549 and existing Rules and Regulations: <br />- --.d <br />- w--�G- <br />S 5 <br />JOB ADDRESS/LOCATION // —i� -------=---------------CENSUS TRACT ------- <br />rvian�rc¢FiUQCom_ <br />fa'- -----Phone -_J g -= --- ----- <br />Owner s Name CrsSe:_ ----------------------------------- <br />. <br />---------------------------------- <br />.- City ----------------------------------------------------- <br />Address -------- ` 5/ <br />.._ <br />Contractor's Name --- .4Xti9►-------------------------------------------------- --------- License # :'_ Phone X----------------_•---- <br />Installation will serve: Residence rtment House Commercial :❑Trailer Court i0 n <br />f s .nt-'1 <br />Motel ❑ Other ------------------------------ ------=------ j�! ' <br />Number of livingunits:._ --Number of bedrooms -3_____ -Garbage Grinder _I--tf--� Lot Size C___AC F -s-_- <br />---------- <br />0� { <br />Water Supply: PXic System and name ----------------- •-"----------- Private <br />Character of soil to a depth 6f 3 feet: Sand g� Silt o Clay ❑ Peat ElSandy Loam -F Clay Loam ❑ <br />- Hardpan E] Adobe ❑ Fill Material _ - _©-- If yes, type ___"____________________ <br />(Plot plan, showing size of lot, location of system in';relation to wells, buildings, etc.�_Ir' est 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'[ ] Size ------------------------------------------- <br />---- Liquid :Depth _.__________--------:-_--- <br />Ca acit Type Material a. Compartments --------------_----- <br />P Y - i-------- - YP <br />Distance to nearest: Well ----------------------------------- Foundation ------- -------------- Prop. Line .---------------_--- <br />LEACHING LINE [;] No. of Lines _---------------------- Len th 'of each line----- _-_----- - Total Length ,______- -----. <br />_ , 'D' Box ------------ Type Filter Mat ial ____ `=--=:Depth. Filter M eriai-------------------------------------------- =" <br />Distance to nearest: Well _-- ______' "__ Foundation .:__---_.___ -__ _ __ Property Line ________________________ <br />Rock Filled Yes No <br />SEEPAGE PIT Depth F__ Diameter _______________ Number ._______.____________ ❑ <br />[] p <br />Wateri-Table Depth ------------------ -------------------'-----_-RoFk Size <br />y Well' A �. <br />Distance to nearest: -------------------=- Foundation ___--------- ---- Prop. Line -------------- .------- <br />REPA1Rf ADD1T{ON_iPrev. Sanitation Permit s# -------- --------------------"----------- Date ----------------- ----- - I <br />--------------------------------------------------------------------------------------- <br />pe k�. <br />� <br />Septic Tank (ScifYRequirementsl--------------- ---------------- --- - - <br />Disposal Field (Specify Requirementsj-_---Q°--d}e�ds/--_-_--__-- t <br />f! <br />- s P1,577'.' -- X ------- --------- -6-T-r-`. �� n1-5- <br />— Z� L) N= 'z-- L1 -CJs = *dTA�— 1 ----`------ ---- <br />�so (Draw- <br />--ex__i_ - -- <br />f (Draw existing and require addition an raver 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. 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, 1 shall not employ any person in such manner <br />as to become subject; to Workman's_ Compensation laws of California.".. <br />Signe -- -- ., s---- <br />------------------ <br />,f� , Owne <br />'Q - - - _ ---=------=-------- ------=- •Title 1� / . i �}�✓' _ <br />(If other than own ,rte w { �! +�. <br />-.FOR. DEPARTMENT_-USE_ONLY <br />APPLICATION ACCEPTED BY -------------"-_---------------------------.- --------- - --_---------------------- DATE -- <br />----" -"- <br />BUILDING"PER1IT-15SUED'- ----------------------------------- - -DATE=---- 7'_--------------------------------------------------------------------- <br />ADDITIONAL COMMENTS - -------------------------------- ---------------------------------------- <br />F ------------------------------------------------------------------------------------------ <br />---------------- <br />------ ------------------------- ----- --------------------------------------------- -•------------------------ - - --- --------- <br />-------------------------------------- -- -- -- ---- ---------------------------------- <br />)} <br />- ---- <br />Final Inspec------------.Daefl <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />E. H. 9 1-'68 Rev. 5M <br />