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FOR OFFICE USE: I <br /> cag J01--7—APPLICATION FOR SANITATION PERMIT <br /> =may----------------- <br /> (Complete in Triplicate) Permit No. <br /> --------------------------- <br /> Date Issued ./,�,3-0 <br /> ----------- -------------- _--------------------- This Permit Expires 1 Year From Date Issued - -------------- <br /> Application is hereby.m ade--to-th6-Sa n-J-oaq-ui n"Loco[-Heal th-D i S-tr I a-fur a­pef7m-It­to-d'6ffstru6f'Z-6d install the work herein <br /> described. This-­a`pplication is made in complianw with Cc)ynty � '�anceo. 549 and existing Rules and Regulationsi <br /> ------ -----)----------CENSUS TRACT ----------- <br /> JOB ADDRESS LOCATION I------ <br /> Owner's Name ------- --- - --- ---- - ------- - ---- - ---�J�--------------------------;­­-------- Phone?_.?/7�X/6_7--------- <br /> ["tlll�--- <br /> ty <br /> toi JE <br /> .,11 --- ---- ----------------------------------------- <br /> AddreS4-----------------------:? <br /> Contractor's Name -- ._.License--------------- ------- Phone <br /> Installation will serve. Residence Apartment House[] Commercial;MF Trailer Court ',E] <br /> II Motel'R.Other I <br /> Number ;f living units:________ Number of bedrooms _____Garbage Grinder ------------ Lot Size ... -------------- <br /> Water Supply: Public System and -name ------------- ---------------------------- -------------_- --------------------------------------------------Private X <br /> I <br /> Character of soil to a depth of 3 feet: Sand'E] Silt E] Clay E] Peat E] Sandy Loom -E] Clay Loam,[] <br /> HardpanAdobe 1% Fill M'Q- b aterial ------------ If yes, type ---------------------------- <br /> ­ ]Z7r* Iation to- wells, buildings, <br /> (plot Plbn, shoW.ihg rsize of lot, location-Asystem4he <br /> etc, must be placed on reverse side.) <br /> i )F 0 f �, -�r,;,Irn. <br /> NEW INSTALLATION3io-)11No septic tank '!�perrnitted if public sewer is available within 200 feet,) <br /> or seepage,.pi <br /> T <br /> ryl <br /> I SF <br /> PACKAGE TREATME7 . P -TANK —Slie---------------------------------------------.-- Liquid Depth --------------------------- <br /> N TIC <br /> Capacity'I------ ------------- Type—-----!- ------ --- Material---------------------- No, Compartments ----------------- <br /> -SiiIE <br /> Distance .to nearest: Well ------------- ----------------0) Foundation -----------kf1------ Prop. Line -------------------_- <br /> LEACHING LINE No. of Lines -------- -------------- Length of each line._____I----------------- TotalkLength ----------- ---------------- <br /> Box ---------- Type (IN P!, <br /> ype J�Jller Material -----------C"t-----De th Filter Material -------------------------------------•------ <br /> t <br /> ------------------------------------ ------ <br /> Distance to nearest: Well _-------_--______'` Foundation --L)hation --------------- ------- Property Line ------------------------ <br /> -- - <br /> SEEP) T Depth ------ ----- -----I Diameter --------- ------ Number - -I----- -------------- --- Rock Fled Yes ENo <br /> C <br /> Water Table Depth - ---------------------------------------Roc <br /> I Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line -------- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------- --------------------------------- --DaO--------------------------------- <br /> Septic Tank JSpecify Requirements) -------- -------- ------------------------ ---------- <br /> _,0------- _�------------ <br /> Disposo.1 Field (Specify Requirements) ----------- <br /> ------------------------------------- ......... ---------- ---- ------ <br /> ----------- ------------------------- ....... ------------------------------------ <br /> --------------------------------------------I------------------------------------------------------------------------------------------------------------- ------------------------------.------- <br /> I (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 Son 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------- -------------- Owner <br /> By Title ... ------------------------- --------- <br /> ---------- ----- - - -------- ------- - ------------------------------- - -----------4f�j_ <br /> fit thejrth a caner) <br /> "It <br /> eARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------i - - --- ------------------------- --------------- ---------- DATE ------/4% -'r"7------------ <br /> -- ----------------------- ----------- <br /> ADDITIONAL <br /> PERMIT ISSUED --------- r---- --- ---- - ------------------------:--------------DAT�n . <br /> ADDITIONALCOMMENTS ------11 - ------- ---------- ---- --- --- -------- ...... - - - - ----------------- ----------------------- <br /> Cy ? Y)4) -------------- <br /> --- - -----------Z----------(f ­_ <br /> ----------- ------------- -------- -t-1VI-ell-- ------2. ---- -- ------------------------- <br /> -------------------------------- - ----------------------------------------------------- <br /> --------------------- --- ------ ---------------------7---------- - - --- ------------------------------- ----------- <br /> 4, <br /> Final Inspection by: ------ ----------------------------- ---------Date ------- ---------- <br /> ---- -- -- -- - -- ---------------------------------------- <br /> N JOAQUIN LOCAL HEALTH -DISTRICT <br /> E. H. 9 1-'68 ev. M <br />