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FOR OFFICE USE: F <br /> APPLICATION FOR SANITATION PERMIT <br /> •---••---...-- -- ---e.......................•--- � � �/J__"77��. <br /> -' (Complete in Triplicate) Permit No. <br /> ............-........................................... <br /> ....................................... ................ This-Permit-Expires T Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health Disitrict fof'a)permitilo construct and install the work herein { <br /> described. This application is made in coin liance with Cou ty 10rdinance-1No,-i.549 and existing Rules and Regulations: <br /> r ' <br /> JOB ADDRESS/LOCATION _.�.�t_gyn..............H.W . _ �_ -------------- .. CENSUS TRACT --------------t....... <br /> `` d <br /> Owner's Name .........l.- JR r{_THrU F-- •--• --..Phone 90---QHQ.��.... <br /> _. ---1-- ___ ---yt�t <br /> AddressIVI A �r-�C <br /> • - - --•- --��-`- --�--'��- ------------------- •---- -- --. City --- - - Fil�.�l-G-��t---------------------------'-----•------ <br /> Contractor's Name ...OWN..IiE �,.......---------------------/...........................License # ------------------------ Phone ----............................ <br /> Installation will serve: Residence�Aparfinent Housef] Commercial ❑Trailer Court fl ! <br /> \` Motel, Other --- .. .. / ----------------•-- ------ <br /> --�Number of livingunits: ._-/ -"Number of bedrooms Garba a Grinder Lot Size_.. ,! <br /> 9 --t------ ------ - <br /> Water Supply: Public System and name .............. .. ..._.____-._____..._._._-_..____ __.'�`.__.____.________.__PriJci <br /> Character of soil to a depth of 3^ feet- Sand: /Silt.0 Clay ❑ Peat(]i Sandy Loam EJClay Loam:❑. � <br /> Hardpan ❑ Adobe ❑ Fill Material .__l].�-. If yes, type ___________________ { t <br /> (Plot plan, showing size of lot, location of system in relation to wells, buil//dings etc. must be placed on3reverse�ide.) ' <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if public s6wer is available within 200 feet,)y t 4 L1 <br /> PACKAGE TREATMENT [ J SEPTIC TANK'[] Size..-6...__..y../Lv..-_.._..._-, _ Liquid Depths .<V-•- .•••.- <br /> i ntsi�^ -':---- <br /> ?- <br /> . �Ca <br /> Capacity Type <br /> Material NO. ompartme <br /> Distance to nearest: Well - ��_Q Fo�datio� . _�QProp. Line __)____�_ ' <br /> LEACHING LINE [�No. of Lines __._.._ ____�—.-_ Length of each line�_._..__.AlP..._ Total <br /> Length <br /> 'D' Box�t✓-.J. Type Filter Material RD_GK----Depth Filter Materia',# _-. .e19�� N--- -••••- •----•- <br /> Distance to nearest: Well ............. .0.. Foundation ;- /V..... P2operitytine. <br /> 1 5- <br /> -- ��-•=-•-- <br /> .. ,, 1J <br /> SEEPAGE P17 [ ] Depth . _... Diameter --------------- -Number �___-.__�.....:_ R6tk Fi---- <br /> i <br /> lled.lY' ❑ No i❑ <br /> Water Table Depth ------------------------------------•- --------Rock Size ._ .-..t.................... --`� 1 <br /> Distance to nearest: Well ---------------..................••.• 'Foundation --.!--• ----------- Prop. Line ..........:- !..-_--• <br /> r <br /> REPAIR/ADDITION(Prey. Sanitation Permit# _..•..............•-....._-.--_-------.----- Date _.-------,____y.__...�__._ ) I <br /> Septic Tank (Specify Requirements) --•-•--------------------------•-•-•--•--••-------•--•-•-------------- -------- -------------­----- <br /> Disposal Field (Specify Requirements) --•---_----._----------------------------------------------- ...................l........!.. ..... .......... - <br /> -- J....................................................................... .......... I . _ ---------- <br /> ------- . ;-- ----�.... ... --- --------;•xy------------ ...�..`.. � <br /> (Draw existing and requiredygddition on reverse side) W ' <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance wiJh San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of tKe'San Joagbin'Local,Health-District. Home owner or licen- <br /> sed agents signature certifies the following: 1` 4 <br /> "I certify that in the performance of the work for which this permit is issued,) shall not employ any per n I-n such m1 anner <br /> as to become subject to Workman's Compensation taws of California." <br /> Signed-.,1...-... - --------------------------- Owner <br /> ��;. <br /> BY -� ------------- / Title _ - . f <br /> (if other than owner) <br /> FOR-DEPARTMENT-USE ONLY <br /> v �"..� ---------•- •_. ..------- -.---...... DATE .......g'.D-'._ }......_. <br /> APPLICATION ACCEPTED-BY _ __ -t- --`•--• -----•-••-•••••-• <br /> BUILDING'-PEIW_IT ISSUED •-----•----.------•----- ----•-- ° ...__.......DATE .......................... ....!._......_.. <br /> t <br /> >VDITIONAL COMMENTS ..-----•--- .............................................................._...........----.....:-----.....�---....--....-- <br /> - <br /> -----•---•-•-•-- <br /> -----•------- - ... --------•...............•-----•--............--•-•---------------•--.....--- <br /> _............. <br /> ------------ <br /> Final Inspectiori'b li, ._ Date .._._ ..... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> E. H. 9 1-'68 Rev. 5M <br />