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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. f1___ l� <br /> ---____----------------------------------------------------- This Permit Expires i Year From Date Issued <br /> Date Issued <br /> Application is hereby made fo fhe San Joaqu�ff-bDcaI-Hpuft'District-for°-a„"per it-'to—cnnstru t grid install the work herein <br /> described. This application is made in compliance witI4 County Ordinance No. 549 and existing)Rules and Regulations: <br /> _,..�.... — �...... - <br /> JOB ADDRESS/LOCATI _ -.--:.7---------'------ - - ------ ------------------------------------ --------CENSUS TRACT -------------------------- <br /> Owner's Name ------------ --- --- Phone 0-71 <br /> , <br /> Address -- - ---------------- iL "--- ----- - ��- - " <br /> �. Gity <br /> - --- <br /> Contractor's Name --__- -- _- :- r—- _ - -- -- -----------.License # �1__.- Phone T0_` a ... <br /> Installation will serve: Residence %Apprtment House❑ Commercial[]Trailer Court ?❑ <br /> a <br /> M o fel. .Ot ez. ----- ------P* --------- ' <br /> Number-of living units:_i... ._ Number of bedrooms ____ �arbagen r _ Lot Size �f �[ j <br /> Water Supply, Y yr t .,-- --- -- - --- -------- ------ Private ❑ I' <br /> ---- - ---------------- <br /> Character of soil to a dedth of 3 feet 'y Sand❑ Silt❑ Clay ❑ Pt;at❑ Sandy Loam ❑ Clay Loam.E] <br /> Hardpan ❑ Adobe Fill Materia)..,_____ If yes, type ____.`------________________ <br /> (Plot plan, showing siz of lot, location of system in relation to wells, buildings; .eic. musft bel placed on reverse side.) <br /> NEW INSTALLATION: No septic tank r seepage pit permitted if ppblic serer is v ilab within 200 feet,) <br /> PACKAGE TREATMENT ] SEPTIC TANK S' e_--____��_ t��r'* 9� <br /> L�qw�Na' <br /> ---------.-Qopacity / _ ITYpe =1 Material. No. omIm r .... <br /> istance to nearest: Well ------------------------------------Foundation ---- � t [1kro{i.'L-41k ---.�s�___ ------- <br /> T, <br /> _____--- <br /> .� _* d . <br /> LEACHING LINE o. of Lines _._ . ._. ------ -- <br /> Length ofd ach line- ?Q-" ----_-- i4l Lengt k�` --to_ ....__.. <br /> .. <br /> D' Box -----V___.-_ Type Filter Material _ �.._.De-Yh Filter Material __________________ <br /> 1 r <br /> istance to nearest: Well x � ._ � lAoundatiQ .�_ _ ' Property Line. -_��.__ "--.--__ <br /> SEEPAGE PIT [ } epth _ Di�eter -_______-_-_------------- Number --------------------------- -hoc Filled Yes ❑ No .0 ' <br /> )Water Table Depth ----- '----------------------------------------Rock Size -------------- -------- i <br /> Distance toearest_ Well ----------------------------------------Foundation ----_----- ------- Prop. Line --_--.------------ <br /> ---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ______________________ t baste ---------------------- ------- <br /> - <br /> SepticTank (Specify Requirements) -------- ----------------------------------------- ` ;; --------------- -------- ------------------------------------- <br /> Disposal Field (Specify Requireents) .-------___.-- ---------------------------------------------------------------------------------------------- <br /> y . <br /> ----------------------------------------------------------------------------------------- --- ------------------------- =------------------------ <br /> -------------------------------------------------------- -------------------- ---------------------------q ----'--- ----- ------------------------------------------------------- ------ ` <br /> ((Draw existing and required addition on reverse side) <br /> I herebycertify that I have p pp icetr� and that the work will be done in accordance with San Joaquin <br /> Y Pre orad this a��t '� % <br /> County Ordinances, State Laws, and Rules and Regulations of thea San Joaquin local Health District. Home owner or licen- <br /> sed agents signature certifies-the following: <br /> "I certify that in the performance ofp 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 tC�mpensation-laws-of-C-alifortsia." <br /> f <br /> Signed ---------------- ------------- ;-` --------- ------ Owner <br /> BY ` ------- Title ------ -_ 192 t, <br /> If of er th owner) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.---, V G`-------------- - DATE <br /> BUILDING PERMIT ISSUED ---------- --------------- ----------------------- ---- - ------------------------DATE --------------- ------- <br /> ADDITIONAL COMMENTS-- ------- _ <br /> -- <br /> ------------------ ------------------------ --------------------------------------------------------------- ---------------------r-------------------------------------------------------------- <br /> -- --- <br /> ------------------------------------------------------------------------------- --- y , <br /> i �� <br /> Final Ins ection b � --- _ � { f <br /> p Y �If - { Date -. -- .� . .7(� <br /> SAN JOAQUIN LLOGAL HEALTH DISTRICT <br /> E. H. 9, 1-'68 Rev. 5M <br />