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7 V <br /> ,FOR'OFFICE USE: '} <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. .-----�_ <br /> J\ This Permit Expires 1 Year From Date Issued Date Issued __ .-__7___ Z <br /> ------------------------------------------------ <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 complia ce with County Ordinance No 5 9 and existin Rules and Regulations: <br /> 139©4 fref�A3� o� c3oi_. v�Plu fz.,� �' �+u�l. r?fawraw Iz� O� brisk 5tn�tE�aP <br /> JOB ADDRESS/LOCATION i/rxL [Lo--{z�._ �tN� --TIS `li__I 1-db_R� .C.af�_ [f0�.- S�JS�TRACT -------------------------- <br /> Owner's Name ----------- pV - ------------------------------------ ---------------------------- <br /> ------------- ---Phone ----- $ <br /> Address --------------------_75--6----'ST, `----•--------------------------- Cit <br /> Contractor's Name ----------------- License # ------------------------ Phone ------ ----------------_---- <br /> Installation will serve..-. Residence KApartment House-E] Commercial ❑Trailer Court ',❑ <br /> "�- Motel [:]Other--------------- --------- ---- ----------- <br /> Number of living units:---_ ----- Number of bedrooms __5_r__Garbdge Grindet ___`_______ Lot Size 1_S;V00_J___s 1._A .___. <br /> Water Supply: Public System and name -------------------- -------------------------------------------- - --------- -------.-Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silto Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes,type ____________________________ <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: (Nonseptic tank or'�&eepage'pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] . SEPTIC TANK' ` y Sizee___________________________________j _ Liquid Depth ___.___________-____..._- <br /> I Capacity ____------------_--- Type i.1'Y1_h_(z_�__ Materim..- t- � No. Compartments ---�----f.._--____•. <br /> 11 <br /> Distance' to'nearest: Well"'-------0-6_r------------------Foundation Prop. Line <br /> LEACHING LINE ,[ ] Nb. of Lines __._ _ ______w___ Len th a e I'ne:_-__._4 __ CNotal Length --- <br /> V Bob ----- Type Filter Material tz[ Lc...___Depth Filter Material _____ ----------- <br /> ------ <br /> ----- <br /> Distance to nearest: Well __7la��T==Foundat•ion __U_�� ' Property Line <br /> SEEPAGE PIT [ ] Depth _-__.__._._________ Diameter ________________ Number -----------.----__------.___ Rock Filled Yes ❑ No i❑ <br /> "Water Table Depfh-------I---------- ------------------------------Rock Size ---------------- •- <br /> - ' <br /> t ti <br /> Distance to nearest: Well _____________________________________Foundation ____________________ Prop. Line ---------------------- <br /> REPAIR/ADDITION <br /> ______--_----_-----_REPAIR/ADDITION(Prev. Sanitation Permit#_____________________________________________ Date ---_______________________________I <br /> Septic Tank (Specify Requirement''s) _- t '---------------------- ------------------------------------------- --------------------•---------p•----------------- --------- <br /> Disposal Field (Specify Requirements) ----------- ------------------------------------------------------------•---•----------- <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. Home owner or licen- <br /> sed agents signature certifies the following:- - - _ _ - . _: .I-. <br /> "I certify that ' e..' rformance of the work,for-which this permit is issued, I shall not employ any person in such manner <br /> as to beco s' e tq Workman's Compensation laws of California." <br /> Signed --------------------------` -- Owner, Y <br /> BY ------------------------------------- --------- Title --- -------- <br /> ------------------------------------------- <br /> ---------------------------------------- <br /> (If other than owner) <br /> FOR DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY --- __.-_ __ DATE ------_______ <br /> BUILDING PERMIT ISSUED - ---------------------------- ---------;--------- DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------- ------------------------------------------------- ----=--------------------------- <br /> ---------------------------------------------------------------------------------------------------- ----------=------------------------------------------------------------------------- --------- <br /> ---- -------------------------------------------------------------------------------------------- -- - - <br /> - - ---------------------------------------------------------------------- <br /> - - -------------- <br /> -- ----- -- ---- - - ---- -- <br /> Final Inspection b <br /> p Y� - ---------------- - ---- - - - -- Date ---/�"" --�- ------------------- <br /> SAN JOAQUIN LOCAL HE' DEST K,T <br /> E. H. 9 1-'68 Rev. 5M {� ' <br />