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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ___�-i!----�-�-- <br /> (Complete in Triplicate) <br /> - -------------- R Zq- 7 <br /> ---- - -� t� �;�j � . . , _- Date Issued - �'------•---- <br /> This PernttEx ires;l Year:From,Datelssued ` <br /> ------------------------- <br /> Application <br /> -------------------- ' t <br /> f <br /> Application is,hereby,made to the Sci ,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:54'9 ani existing Rules-and-Regulations: <br /> . J„. <br /> JOB +ADDRESS/LOCA? N --------------------- ----- _ -- -----=------- -- ------- <br /> -----CENSUS TRACT __•---------- <br /> ^ti.F 1 Phonec '_ d <br /> ` 1 -----------------•----------------- <br /> Owner"s. Name ---•- -- -CSI/� -_l11_�_ /`-- �r-�1�1�------ <br /> Ll- -_.-i_7.- � cityf � <br /> �y _ . _ <br /> dress - / N <br /> t 1" r� /` fl License 7-C3 � -+---- Phone _ ---- <br /> -- <br /> Contractor's Name __ - .@•---• ---- - - <br /> Installation will serve:{ I— Residence ❑ Apartment House,❑ Commercial :❑Trailer 6ot"t <br /> Motel ❑Other --------------------------------------------- <br /> 21 <br /> Number of living units:.__ ___ _ Number of bedrooms __.2�-.Garbage Grinder .- ------ Lot Size - - -P-,� <br /> — -`# ` riva Lr <br /> Water Supply:Public System andhame -----------------------------------------= � - P ' to <br /> Ia Peat Sand Loam Clay Loam 'E] <br /> Character of;soi&I-t_o a depth,of 3 feet Sand's Silt❑ Clay ❑ ❑ Y ❑ y <br /> _ ; <br /> 1Hardpon ❑ Adobe ❑ Fill Material ------------ If yes,type ------_------------- ------(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 is k or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ]i - C Size_ ! _ O -- Liquid Depth _'T- -•------------- <br /> ------------------ - - <br /> SEPTIC TAN1C� --- -- --- -- � - - - �. <br /> P No. Compartments - ---------=---- <br /> Capacity /� ------ - TYp -------- ---------- Material 'tt / B y� <br /> ' C� , Foundation ----------------- Prop. Line _5 ------------•--- <br /> Distance—tom-nearest: Well ____s _ <br /> LEACHING LINE No. of Lines ____ _______________ Length of each line.____ ____----.______ Total Leng`h __ l�® ' <br /> ___De Depth Filter Material __ �------------------ -----_--- <br /> D' Box/4-: Type Filter Material --- p <br /> . r ------------------- <br /> SEEPAGE <br /> f <br /> -- Foundation -------U Property Line -:5- -----------•----- <br /> � Distance to nearest: Well ___._ _ <br /> ---------- <br /> SEEPAGE PIT [ Depth -------------------- <br /> Diameter ---------------- Number ------ --------------------- Rock Filled Yes ❑ No C3Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> 4s, 1 <br /> - <br /> Distance to nearest: Well ---------------------- Foundation -------------------- Prop. Line -------­------------- <br /> REPAIR/.ADDITION(Prev. Sanitation Permit# ------ -- - = Date ----------------------------------) <br /> Septie-Tank�(Specify Requirements) ------------------------------r � y� - ---- ------------------------------ ----- <br /> ------------------------.----------------------------- <br /> Disposal Field (Specify Requirements) �1_ c h� b-N,D.I DIFF__ <br /> ' � )�,�-----�a�1_,---------- --------------------- - <br /> ----------------------------------------------- <br /> ------------------------------------------------------ <br /> ----------------------------------------------=------------------------ --------------------------------_----_------------------------------- ---- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certifythat 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 /> fi Signed __._ -_ Owner <br /> - ---- ----------- - ------------------------------- <br /> --- ----------------------- <br /> , �� Title --.-------- -- ------------- ----------------------------------- <br /> (If other than owner! <br /> /---------- ----------- <br /> r) FOR DEPARTMENT USE ONLY <br /> " <br /> APPLICATION ACCEPTED BY <br /> �--�� ----------------------------- ----------------- DATE_-_--�I___l_.�_ -�. _t------------ <br /> - <br /> BUILDING PERMIT ISSUED ------_ ----------- ------------------------------- <br /> -- ---- ----------=--- ---------DATE --- -------------------- --------- ----• <br /> ADDITIONAL COMMENTS ---------- <br /> --- <br /> --------------------------------------- <br /> ------------------------------------------------ <br /> ------------- <br /> - <br /> ---- <br /> - ------------------- ---- ------ <br /> -------------------- -- --- <br /> 1 <br /> ---------------- ----------------------- -- -- ----- <br /> ------------------ <br /> ----- --- -- <br /> -------- <br /> -- -- - - - -------------------------- <br /> ------------------- <br /> --------------------- D----- <br /> Date - - - <br /> Final Inspection r. - <br /> a -- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r E. H. 9 1-'68 Rev. 5M <br />