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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. �e.�V <br /> - -,- - :7 <br /> (t ------------- <br /> ------------------ <br /> {Complete in Triplicate) <br /> - <br /> ------------- -------------------------- ----- Datt.Issued - ----------16------ -69 <br /> --------------- This Permit Expires 1 Year From Date Issued <br /> ----------------------- <br /> ApplJcation 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/LOCAT�ION-�Z-�._IWZ ___.!5�__V ---9019D-------------------- ......CENSUS TRACT -------------------------- <br /> Owner's Name --- ew-------- -------------------------------------I-------------------Phone,_i_19j?=3 <br /> Address :,�_o 9�6�4 r 2 ------------ city _4�644_o.^J---------------------- <br /> VXA I 'C_ f ---------------------- <br /> __4 ------------------- ----I- <br /> ------------ <br /> nse Phonee? <br /> Contractor's Name ----7 ----------------------------------------------Lice <br /> Installation will serves ResidMotef <br /> E]Apartment House,E] Commercial rE]Trailer Court 0 <br /> Other ------e!YPRMIF7-1104`-� <br /> Number of living units:.'-./------ Number of bedroomsA--------Garbage Grinder All---- Lot Size -------- <br /> Private 9].,� <br /> Water Supply: Public System and name�_.J_I-------------------------­----------------------------------------------------------------------------- <br /> Sand' ilto Clay El Peat E-1 ❑ <br /> Char(icter of soil to a depth of 3 feet.., Sandy Loam 0 Clay Loam <br /> Hardpcin F-1 Adobe F-l 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 /> IV <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public;ewpr is available within 200 feet,) loy <br /> PACKAGE TREATMENT I SEPTIC TANKJq" Size-9- 2�r_7Z1-!F_A........... Liquid Depth _31. ----------- <br /> Ca pacity.-I :�Z e10------ TypeOW- 7--W----- Material!13W No. Compartments --------_------ <br /> ----- <br /> t 1 01' --,0? <br /> Distance to nearest. Well ---------------Foundation __/0-------------- Prop. Line -_q ------------ <br /> LEACHING LINE No. of Lines --- ---------------- Length of each line-J42-0-- ---------- Total Length J ---------------- <br /> I <br /> 'D' Box --- ---- �Type Filter Materiole&C_&--------Depth Filter Material --- --------------- ----------- <br /> Distance to nea�.estf: Well ------ Foundation J -------------- Property Line dv_.�6�----------------- <br /> SEEPAGE PIT Depth --------------------- Diameter ---------------- Number ---------------------------- Rock filled Yes [_-1 No 0 <br /> Water Table Depth --`-------------------------------------------Rock Sire -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- --------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------- ------------r-------------- -------------------------------------------------------------------------------------------------- <br /> DisposalField (Specify Requirements) ----------------------------------11----------------------------------------------------------------------------------- --------------- <br /> --------I ------------------------------------------------------------------------------------- <br /> ------------------ ---------------------------------------------------------------------------------- I-------- <br /> V�, <br /> ----------------------- ---------------------- ---------------------- <br /> ---------- ------------------------------------------------ ----------1----------------------------- <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Jo6quin Local Health District. Home 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, rtihall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------- --------- ----------- ----------------- ----------------------- Owner <br /> ----------------------- ----------------- Title -se ---------- <br /> By <br /> (if other than owner)Cq <br /> FOR DEPARTMENT USE ONLY <br /> 7- <br /> APPLICATION ACCEPTED BY ----I`-T.'t_ -------- -------- DATE <br /> rN - --------------------------------------------- _..__L --- I--- - ------------- <br /> BUILDINGPERMIT ISSUED ------------------------ -------------------------------------------------------------------- ----------DATE --------------------7 ------ <br /> ADDITIONALCOMMENTS --- -------------------------------------------------------------------------------- ------------------------------------------------------------------------ <br /> - ------------------- - ---------------------------------------------------------------------------------------- <br /> ----------I--------------------------- --- --- ----- ------- -- - ------- --------- ---------- - -------- <br /> -------------------- ---------- ----- ---------- ---------------- - <br /> Date------- <br /> --------------------- <br /> ---- --- - ------------------- --- ------ ---- <br /> -by: --------------------------------------- .. <br /> Final Inspection ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT-- <br /> E, H. 9 1-'68 Rev. 5M <br />