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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ; <br /> i <br /> 0 Permit No. ................. 3 <br /> f ............... ............. . <br /> .4� <br /> (Complete in Triplicate) <br /> ..................._.......�.... . ._.. ,... .:-- �� Date Issued _,�`:....."...... <br /> I� This Permit Expires 1 Year From Dale Issued <br /> w <br /> Application is hereby made to the San Joaquin Local'Health District for a per 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/LOCATION........1221_.N_0....;_Go1,den...Ga -e...-r,.... CENSUS TRACT .................. <br /> t Owner's Nome .......Down..Rivar-...Forst...P�o-c�.................:. <br /> i Sams _._.... city ....S-'I�s�cktorl..... .............................. <br /> .. <br /> Address ..- i ------ <br /> _ c + - _-License ...--2:68 1 Phone .._ �70 <br /> Contractors Namew..---'B1 kard'--s. :�e: �:_c•--�'an] =: y �' --'' <br /> Installation will serve: Residence E] u <br /> Apartment Hose Commercial []Trailer Court ❑ <br /> Motel ❑Other ------ ---------- <br /> Number of living units.,...!..Q.... Number of bedrooms --�-------Garbage Grinder .-.......... Lot Size ..-'.- `- ©y'e's <br /> ( i <br /> l; Private <br /> Water Supply: Public System and name ............ <br /> F Character of soil to a dept of 3 feet: Sand❑ Silt❑ Clay (] Peat.❑ Sandy Loam ❑ Clay Loam ❑ , <br /> iL <br /> Hardpan ❑ Adobe ®' Fill F iMaterial ............ If yes,type ........................... <br /> (Plot plan, showing-.size.:��fjot, location.of system in .relation-to wells, .buildings, ete.-must be placed on reverse side.) <br /> NEW INSTALLATION: (No, septic tank or seepage pit permitted jJf public sewer is available within 200 feet,) r <br /> ..... . Liquid Depth .................• ..... "i <br /> 'PACKAGE TREATMENT ( SEPTIC TANK[ ] • � Size ----------- ............. <br /> ................... q P <br /> ' Capocit ' 'Material.----- .-.--....... No. Compartments .................... <br /> }�; k .t..._._..._Foundation .... Prop. Line ...................... <br /> Distance to nearest: Well <br /> . :. <br /> �I' Len th of each line ....:...8 �_......-".-- Total Length ...._._._ 0.'............. <br /> LEACHING LINE k] No. of Lines 1 <br /> t V Box -3- Type Filter Material ...2.............Depth Filter Material ..---- ......... ...... <br /> .0. Foundation :.' �D.+'=-----'•' PropertyrtYL�Q+ <br /> ...... <br /> 'Distance to nearest: Well ................. <br /> L SEEPAGE PIT ] Depth 2 +.......... Diameter -. ��--•- <br /> Number .._...._.....2.........-.. Rock Filled Yes a No <br /> Rock Size •-------.2'+.._.._..--- ------ y <br /> I Water Table Depth ........---9o-,------- ----------. " <br /> .... <br /> .11, d ..Foundation ........:a.! ... Prop. Line .... •.Q!..........fq <br /> �} <br /> Distance to nearest: Well -..--._..�...._��...�...-..._._ <br /> } III! f �. '--•-... Date _-..12/14: 6'7---------I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --.----- •"-'•' . <br /> I!I a <br /> .-.---- ...............�+---t° .. .... '------ -- ----- ._. <br /> Septic Tonk�(Specify Requirements) <br /> : <br /> Disposal _Field (Spec'if-y' Requirements) ..............9o•t-- Leac-Y- L1n-e..'&---f2}.- Pits........... <br /> ---------- ...................----- .... ......_......-----....... - .. •--...... -...-.__ .._� <br /> - (Draw existing and required addition on reverse side) <br /> ( I hereby certify that I have prepared this application and thatslthe work will be done in accordance with San Joaquln <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licen- <br /> i secs agents-signature certifies.the following: Ei . person In such manner <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> a as to become subject to Workman's Compensation laws of California. <br /> Signed - a <br /> Owner <br /> Title . .... .. . ... ...Cxac.i;o.r.......... <br /> � �`..---...'. ---- <br /> (If other than owner) _ <br /> ` FO- PAR7MENT USE ONLY <br /> -- —----- - T -- p� <br /> f .............. DATE ._,��� .... - •- <br /> APPLICATION ACCEPTED BY --'- "-.... .............._..... <br /> BUILDING PERMIT ISSUb .... r M. - ........ ': ........DATE . ...................... ......:.......-• <br /> ADDITIONAL COMMENTS - ----- ----- `.. <br /> " ................ ...... <br /> li. . - . ...... " <br /> �� - -- ----- --...-----. <br /> --•-----...---'-----"-------- - ...__Date ................. _. <br /> 3 Final Inspection b � <br /> `,,/ <br /> N AQUIN LOCAL` HEALTH DISTRICT <br /> i <br /> 3 X <br /> 7172 <br /> 13 24 n �c oe., ri" - -- <br />