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.FOR OFFICE,JE:r 1 i APPLICATION FOR SANITATION PERMIT <br /> �. Permit No, <br /> --------------- <br /> �< <br /> (Complete in Triplicate) <br /> Date Issued <br /> �---- -------- ------- --- /��----- ✓ <br /> This Permit Exp ires 1 Year From Date Issued i <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> U 1hG ✓t . ------------------------- <br /> -CENSUS <br /> TRACT <br /> --------------- <br /> JOB ADDRESS/LOCATION . 7�� - `ate N <br /> ( � 1./��C ------------------------------------------- ------------ -------------------Phone --- ---------------- <br /> Owner's Name - t _ _ •--- _ . <br /> ( C �_L---------. Ci# �S?'l{1 ---------- --------------------------- ------------ <br /> Address ---- ` uhf l/T//_= Y <br /> Contractor's Name _.�k --- S � � � <br /> �lC ,.License # -`65�- Phone <br /> Installation will serve: Residence [,Apartment House'❑ Commercial ❑Trailer Court <br /> Ej <br /> IMotel ❑ Other -------------------------------------------- i <br /> Number of living units:.--__-.-- Number of bedrooms __ ------- Grinder ALP Lot Size _--�1JPi�-Private <br /> Water Supply: Public System and name -------------------------------------------------------------------------------- <br /> - -- - la Lo <br /> Private ] <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat ❑ Sandy Lo <br /> am ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe:9 Fill Material _____.__.__-_ If yes,type ------_--------------------- <br /> (Plot <br /> _____________ --(Plot plan, showing size of lot, Location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic#tank or seepage pit permitted if public sewer is available within 200 feet,) d <br /> Depth <br /> PACKAGE TREATMENT SEPTIC TANK'[ j Size_.-____---_ "--- ----------- --- - -------- Liquid <br /> --------------------- No. Compartments <br /> nts ----------••------ <br /> Capacity - -- ------- -- - TYP <br /> Material <br /> L <br /> Distance .to nearest: Wel! ------------------- ------•Foundation ---------------------- Prop. Line ----.--------- <br /> Distance <br /> ---- .: <br /> LEACHING LINE [ ] No. of Lines ---____-_ <br /> Length of each line ---- Total Length -----------•-._-..- <br /> De Depth Filter Material ----------------------------------- -----" <br /> r � -• � 'D' Box -�-�---"- -- Type Filter Material F ---------. P <br /> .t Property Line. -------•-•---------=---- <br /> Distance ao nearest: Well ------------------------ oundation ------------- -- P tY <br /> I ^____ Diameter __ Rock Filled Yes No �] <br /> ! [ ] Depth Number <br /> SEEPAGE P17 --.--- --- <br /> "+ Rock Size ------------------------- <br /> Water Table Depth ------------- --- ----------------- ------- <br /> I I Foundation Prop. Line <br /> r Distance to nearest: Well _______��------- - <br /> -------- <br /> REPAIR/ADQITION(Prev. Sanitation Permit -------- ------------------- <br /> ---------------------------- <br /> ---- -- <br /> ------ <br /> Date ----------------------------------) <br /> I + -------•�----------------- ----•---- <br /> Septic Tank (Specify Requirements)------------------------------------------- --------------�Z x;e_iv�--- F J� <br /> I. - npx-------------yQ �� <br /> F Disposal Field (Specify Require ments) [�- <br /> k ___.___-.�________________________ <br /> ___----__._-""--.___-_-.-_""__._-"___-_-"_____________________________________ <br /> I ____ ___ ___I_".-_____________________________.__._"---__"_---____._---______--_____-"-_________--__.____--_"____.--__.____--_.._.__-_____-__ __"-_.__-______._ <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 /> of the San Joaquin Local Health District. Home owner or licen- <br /> County Ordinances, State Laws,.and Rules and Regulations <br /> I sed agents signature certifies the following: <br /> E <br /> "1 certify that in the performlance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becom ub)ect to W rkmdn's Compensation laws of California." <br /> Signed �` - - ------ <br /> Owner <br /> t ----- <br /> BY ------------------ <br /> ----------------------------- ---- <br /> -------- Title <br /> (If of fir-than--owner)' <br /> OR .QEPA TMENT USE ONLY <br /> - DATE -----lr-~---- _- <br /> ' APPLICATION ACCEPTED I3Y f,°_. fir-- ------DATE -------------•- --71 <br /> ----------- <br /> BUILDING PERMIT ISSUED --------i----------- ----------- -------- ---- <br /> ----------------------------------------- <br /> ADDITIONAL COMMENTS --------- ------------------- -------------------------------"------------------------ <br /> ---------- <br /> ------ <br /> - -------------------------------------------------- <br /> ------ - <br /> ----------------------------------------------. - ---- :.:�_(i--------- <br /> - - - D <br /> ir -- - ---- <br /> by inspection <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 51;X •f y <br />