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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .............................:........................ <br /> .: Permit No, Z.. <br /> _A <br /> (Complete In Triplicate)--•1111-----1111._. <br /> + - �1 This Permit Expires 1 Year From Datefssered Date <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 /> JOB ADDRESS/LOCATION .._.._.off !P�!-_7 c..: G_.N... . _ ................:...... CENsus TACT <br /> ............ ... <br /> Owner's Name ..._�. �.� Sam! _4.21/�S ............ ...........:.....................Phone <br /> 1111._.. 1__111--1111-- _11.1.1.:---- .................................... <br /> Address <br /> _4_117........ ........ c1 city lY�. r✓ ............................................... <br /> Contractor's Name r� <br /> lV�-P....•....... ......•---•-. ...License 1VV/����._ Phone .���..._._._�.._ <br /> Installation will serve: Residence©Apartment House Commercial❑Trailer Court ❑ <br /> Motel ❑Other ..................... <br /> --••1111-1111.. ...... <br /> Number of living units-----�_..._ Number of bedrooms z Garbage Grinder Lot Size �/ -t7............. i <br /> --- ------1111.. _11.11�...-�`-1111-- ---- <br /> Water Supply: Public System and name ........................................................-._.................................. ...............Private 0 <br /> Character of soil to a depth of 9 feet: Sand'($ Silt d Clay ❑ Peat❑ Sandy Loom 0 Clay loam ❑ <br /> Hardpan Q Adobe 0 Fill Material ........... If yes,type............... ....:....... <br /> y. <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 240 feet,) <br /> PACKAGE TREATMENT j } SEPTIC TANK{ ISize....../a -. <br /> ...........••__........_ ..._..: Liquid Depth 1111-- <br /> Capacity . 'type . Mal.._.....I.. --..._ No. Compartments <br /> •1111.............. 1 111----••--= -----....-----........ � <br /> Distance.to nearest: Well 111.1........:.. ........ ...Foundati ..........__..._....__ Prop. Line -----_.--------------- <br /> LEACHING LINE [ } No. of Lines ----------- ......... Lengt of ealine........ . ............... Total Length --•1 _---.---------------- <br /> 'D' Box ............ Type Filter Mate al ......... ...Dept Filter Material ..........-•--------.-•------------- <br /> Distance to nearest: Well ---.. ._.-._.-.- Ftio ........................ Property Line --- ................ d <br /> SEEPAGE PIT [ j Depth Diame .........:..... e ................I............ Rock Filled Yes ❑ No C], <br /> Water Table Depth ---Rock Size ...........::.................. <br /> Distance to nearest: We ........................:... Foundation _1__..•111-:_1111.._ Prop. line 1111•................- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..............•..__._..._.....•--.: Date ...._....-- ._.:_.........._..I <br /> Septic Tank (Specify Requirements) ------- -•--•- /...... .. .................... .......... <br /> ------- <br /> & <br /> - j <br /> Disposal Field (Specify Requirements) ......._.1.. ., _. C <br /> -o:p �, 1 .._.. ..................................................... ...... ......... ......... <br /> - ------------------------------------------------ -------- --------------------------------------------------.......................... ..........................................--_..................... <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 /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.District. Hoene 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 Workma 's Compensation laws of California." <br /> Signed -------------- - Owner <br /> --- - - 1111-- --- •--�1111 ---....................... Owner <br /> --------- ---<---- - .� ............... Jitle <br /> .............. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION..ACCEPTED BY - .....--------------------------...--- - ._......_.-._<- -----. DATE ��......—------- <br /> f BUILDING PERMIT ISSUED ----- ------------------------ 1-••-----------1111-- <br /> 11.11.--•---------DATE -_-------------------_- 1 <br /> - •111. <br /> ADDITIONALCOMMENTS --------------- - - •--.._-.._....._....---------_......•------••-----.._..---..........--­_­­__­_­_1..................... ......M-..........I..... <br />�. ------------------------------- -•----------------------------•---------------------- --------- -. --------------------------• ---- ._..._._.._.....-----•.....---•._...---.......... <br /> -------------------------•--------------------------- ------------;----- ..----------. -------..._._------_-..-------•---•-------... ................-------•-•--------------------................. <br /> ----------------------•1111--1111•- -.. .-- ------•--------------.............................._...:....................1-.__................1111.. _ .. _ 1111 ._.. -r� <br /> 1 final Inspection by: ....................__.............. ............: --------------:_. <br /> EH 13 2L 1'68 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br />