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FOR OFFICE USE: APPLICATION F , <br /> FOR SANITATION PERMIT <br /> q, Permit No.;__.___-'--- -- <br /> �t <br /> --------------------------------------- <br /> ---------- (Complete in Triplicate) } <br /> �= <br /> -- ------------ Date Issued -5- <br /> This Permit Expires 1 Year From Date Issued - - ' <br /> San �-" <br /> Application'is Hereby made to the 'Joaquin Local Health District for a permit to_ construct and iinstall the work herein <br /> described.' This application is`made in compliance with County OrdinanceNo:'S49 and'exis"ting Rules'dnd"Regula#ions:�"'�"'"""'� <br /> JOB ADDRESS/LOCATION .- 6--- 1�e- �y <br /> ------ f tl -- �r /11 ---�L`--ZwDe—CENSUS TRACT --- --------- ------ ' <br /> ` ,�/ff> � <br /> ---------------Phone�Pj�_`rr�`7•---------•- <br /> Owner's Name -------------------------------- -------------------- / <br /> Address ------------------- ------- �� :' '' -------------------------------------------- <br /> -45-//---- <br /> - --------------------- -- <br /> --�_ City Llrl(/D�l ;C+�1--------------------------------------- <br /> ' � �� ��, ------ <br /> i- -.License # - - O�. f Phone - <br /> Contractor's Name ... <br /> 11-_�A--�'_-_'�� <br /> installation will serve: Residence $Apartment House-0 Commercial ❑Trailer Court ❑ <br /> I --I ..' F E kMotel ❑ Other ---- ------------------ - <br /> ------------------- <br /> ='4t & ' <br /> g its:___1-__-_-- Number of be'drobms C�).---_Garbage Grinder -.----.__-- Lot Size _� 'i ------------ <br /> W t <br /> Number <br /> r Supply:fPubl ct i -~ Private <br /> ystemand name ------------------------------------------ --------------- <br /> Character of soil to a.cJepth of 3 feet: Sand'[] _Silt 0 i , Clay ❑ Peat❑ Sandy LoomF% Clay Loam ❑ <br /> R., Fill Material ------------ If Yes, type ------ <br /> i <br /> F .. 'ardpan ❑ Adobe ❑ ------------------- <br /> H - <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 septi to�k or seepage.pit,permitted if public sewer is available within 200 feet,) <br /> 5ize--------- - Liquid Depth ----------------------- <br /> 7 <br /> --.4-------•-- •--,- <br /> PACKAGE TREATMENT SEPTIC TANK:[ ] -% �t,. -- Material------------------ -- No.ECompartments ----------------------- <br /> Capacity <br /> s------------------ <br /> Q <br /> Type <br />! Distance to nearest: Well _______--_'_-�---------------------Foundation -___F- -_#-_---- --- Prop. Line_______--------___-.- <br /> T <br /> otal Length <br /> LEACHING LINE 'No. of Lines s----------------- Length of each line--------- <br /> Box TypeFilter Material --------------------Depth Filter Ma'ter'ial <br /> --- tf <br /> R -- _-- Foundation - '---------= Property Line <br /> ------------------------ <br /> Distance <br /> .. Distance to nearest: Well ---___--__---___ __ . <br /> t �. `_�- I Rock Filled Yes ❑ o I❑ <br /> SEEPAGE PIT [ ] Depth -------- \fDiameter Number ---------------------------------- <br /> {Wat t-Table-Depth ------------------------------------------ -------Rock Size ) <br /> i Foundation ------------ <br /> Distance ---- Prop. Line `--------------------- <br /> to nearest: Well -------------------------------- <br /> .. Date -------------- = ) <br /> REPAIR/ADDITION(Prev. Sanitation Permit,# ---------------- --. <br /> I % <br /> - ------------------------------------------------ <br /> A-'. = ------------------------------------=-- --------- <br /> b T <br /> i Septic Tank,(SF pec-ify Requirements) <br /> nts) -------i--= <br /> --------- - - --------- <br /> Disposal Field (Specify Requirements) AI/�I � ----i----- ------ - <br /> ` _�� �---x--- ------- ------------------------- <br /> -------------------------------- a <br /> ;.` , -------------------------- ------------------------ <br /> ---- --------------------------------------------- <br /> J, <br /> --= ---------------------------=-------- - <br /> ' �,J, (Draw existing and-required addition on reverse side) ' <br /> I hereby certify that I have prepiired this application nd'that the work will be dine in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules_and Regulations of-the. San Joaquin Local'Health District. Home owner or licett- <br /> i <br /> sed agents signature certifies the followinb: i . <br /> + <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 /> - _ ' _ Owner ` <br /> r. l .. <br /> Signed - �- - -�����c �►_---�------ ---r--- --- - -- r <br /> ' Title ( -- <br /> 4sz <br /> othe than owner) - <br /> " # ti FOR' DEPARTMENT USE ONLY <br /> I DATE ---: -7 _A a 4- ----------------- <br /> APPLICATION ACCEPTED BY --- ----------- --- -- ----- -- <br /> -----------------= <br /> PERMIT. ISSUED ----------------------------- <br /> ------------ -------- <br /> BUILDING DATEk <br /> ADDITIONALCOMMENTS -------- ---------- ------------------------- ------------------------------------------------ ----------------- ------- <br /> ----------- ---------------"-------------------------------------------- <br /> ------- ------1-----_---_------ _ _--____---------_--_-_---___---_---__-------- ---__--_-__.----__--- �__-_-- .-_--__---_-----___--___--"---- --- _ ------- <br /> -------------- -- - - ----------------------------------------"-_-_.__-.___-----_--"-"-__ --" u <br /> / --------------------- ------ t Date -- � f & <br /> Final Inspection b �-��_----- 11-�- ------- --------- ----------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />