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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ----------��'----- i <br /> 17--- -----/�'------------- <br /> � (Complete in Triplicate) <br /> ..: <br /> Date Issued _�-�`- <br /> --------- <br /> This Permit Expires 1 Year From Date Issued y <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 5.49 and existing Rules and Regulations: <br /> CENSUS TRACT <br /> � -------------------------- <br /> 4 JOB ADDRESS/LOCATION ------ �- c� <br /> �s� -- - - - ---- -----Phone ---Tr6- <br /> Owner's Name ------ -----���----- <br /> - City ------------ <br /> W <br /> Address ----- . Phone <br /> ------- ---- - - = - -------- �!(p <br /> � ,2 # ---------: ------ <br /> Contractor's Name _______-- -- "�� " " " --------------------L'icense <br /> Installation will serve: Residence X.Apartment House Commercial :❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> -------•------ <br /> Number of living units:----- Number of bedrooms ---:�.Garboge Grinder - "_-_ Lot Size Private 1:1Water Supply: Public System and name ----"----- ZAA� ---- '� '` -"""""" <br /> Sand Loam Clay Loam :❑ <br /> Character of soil to a depth of 3 feet:�Sand'❑•- „•Sift❑ CIaY`.[ Peat❑ Y <br /> Fill <br /> y e ---------------------------- <br /> Hardpan ❑� Adob , Fill Materia{ _"-_______-- If es,type <br /> ` F <br /> (Plot plan, showing size of lot, location ofi"s�j%st&n in relation,to wells, buildings, etc. must be placed on reverse side.) <br /> I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted &publiewer is available within 200 feet,} <br /> ..��.. _7 w Liquid .Depth "_ <br /> PACKAGE TREATMENT:[] Size"-`'�-__•_ ----- --- <br /> SEPTIC�TANIG [_J. . �.. � ;� <br /> ..._ _ <br /> _" Na. 'Compartments - --------------=----- <br /> T e _ _ ----- Materia[-------- p \ <br /> Capacity -------------------- Ty -- <br /> Distance to nearest: Well " -- --= <br /> Foundation -------------- ------- Prop. Line <br /> No. of; Lines ------------------------ � ength of each line '----------- Total Length __-___•------ <br /> --------------- <br /> LEACHING LI E [ ] ;.. I N. 1 l ------ <br /> I -------------------- <br /> t- "v' 'D' Box -.- " Type Filter AAa#anal ----- P . <br /> '4 I id th Filter -- Pro a Line -------------------•- <br /> Distance to nearest: Well ---- "kw -"----.----(Foundation --" p �Y <br /> Depth Di l -_- ` Number.......1---------------------- Rock Filled Yes ❑ No <br /> SEEPAGE PIT L 1 De p - ameter - -- 1 <br /> XNJ <br /> Water Table Depth r4. _.Rock Size _-.____-- ---•--------• <br /> Distance to nearest: Well ------- ----- ------{ -=ST---- Foundation -------------�----- Prop. Line ------------•--------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _.�--__ --- <br /> -------- Date ------ -------� <br /> F - ----------------------•---- <br /> p (SpecifyRe uiremEi ). - - -------------- . ------� <br /> Se tic Tank ' q' F "� r <br /> -- ---- -------- ------------------------------- <br /> Disposal Field (Spl cify Requirements] ____-, . ��(-,- -- �! <br /> - -• - <br /> ---- - <br /> t€a;. ��----------- ----------`- -------------------------------------------- <br /> -- -_ --- <br /> s .idl <br /> (Draw existingand requit"ed'�"add�t�on o��'teverse side) <br /> 1 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. Home owner or licen- <br /> sed agents signature certifies the following: I"I certify that in the performance of the work for which eFri�permifi is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's opensatoilaws} 'Cblifornia." <br /> Signed <br /> -------------•---•-------------- Owner <br /> .._ -- <br /> -r------ ------------------------------ <br /> By . Tit e --------------- --- ----- - -------- ------ - -- - <br /> (If othe n owner] <br /> FOR DEPARTMENT USE ONLY <br /> -?77 <br /> APPLICATION ACCEPTED BY ". ---"------------------- <br /> ----------------------------- <br /> - DATE ---------0'_"1'0�-------------- <br /> BUILDING PERMIT ISSUED ------=----------------------------------------------------------------------------------------- DATE <br /> /�DITIONA4 COMME1xTS t - y <br /> I- 'r----- 1k --1-ta g5---ile d}------- il��- __� ` x 3 ° L = - - ---------- <br /> -----------------------------------r ---------- --- ------ -----------r---------------------- ----------------------------------------------------------- --------- <br /> q - -- . <br /> ----------------------------------- <br /> r = <br /> - <br /> ---------- ------- ------- - ------ to ---- --�...... <br /> - -- -- ---- - -- ---- <br /> Final fns action b `�� � - <br /> ------------------------------ <br /> - -- --- --------- ------- - ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'08 Rev. 5M _- _ <br />