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FOR OFFI.CE USE: '� G <br /> li APPLICATION FOR SANITATION PERMIT , r{ S <br /> ............................•............... <br /> I) Permit No. <br /> ;Complete in Triplicate} • •----•-•� <br /> - This Permit Expires f Year From Date Issued Date Issued ...!J:+..__._... <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------ •_S7r? .---�`"�'�'`�----�_R........ %- ----------------------------------CENSUS TRACT ----- -�'�_----------- <br /> Owner's Name -------------.-h. 1 RTZtU-- p-�S�� °�2�....................--------------........................Phone 8 .-r_ ?_.2_...-. <br /> Address .........-- �4'r ..:l l�2.t_Y--A-f21 ► •i•RA oi-------------------•--•City ---------------------- - -------------------------------------------------- <br /> Contractor's Name --------- . ....... -------•_()Wuft-.--••--•..... ...........................License # ...... ........... Phone ...."_" --_--------_--- <br /> Installation will serve. Residence[ Apartment House[] Commercial oTrailet Court ;❑ <br /> Motel ❑Other ........................-.................... <br /> Number of living units:.._,.,,,....... Number of bedrooms ............Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply. Public System and name -------------•-••-•-- ...................................—.............V.......................................Private ❑ <br /> r <br /> Character of soil to a depth,of 3 feet: Sand E] Silt Q Clay ❑ Peat❑ Sandy Loam-[IClay Loam 0 <br /> II Hardpan ❑ Adobe-❑ Fill Material ............ If yes,type ............................ <br /> (Plot plan, showing of lot, location of system in relation to wells, buildings, etc. must be place15- <br /> on r e side.) . 04 <br /> NEW INSTALLATION: (Nb s ' tank or seepage pit permitted if public sewer is available within 2 t,) <br /> I, air.. <br /> PACKAGE TREATMENT [ ] SEPTIC TA Size------------------------------------ • id Depth .......__...........,_-_._ <br /> Capacity •--------------- • Y ---....••.... Material--_.----- -- •• No. Compartments ...................... <br /> . T _ <br /> Distance to nearest: Well ................ ................. dation ..___-_•. ............ Prop. Line_.....__--... ........ <br /> ii <br /> LEACHING LINE [ ] No. of Lines ........................ Length of e__-------•---:--- ---------- Tota} length :--------_- <br /> 4 <br /> D' Box . TYP? Filter'M of ........-••••-•-•-••DeP Iter Material -------•-•------•--••-=---•-•-•---•---- ---- <br /> i <br /> Distance to nearest: ....._.---- Foundation --------------- ---- Property. kine <br /> SE&AGE PIT [ ] Depth ----- ........... Diameter ._..._..._...... Number ......._...._............... Roc ed : Yes [] No i❑ <br /> r Table Depth • ----------•-•......----••........Rock Size . <br /> Distance to nearest: Well ............................_.-__-----._Foundation •_-.._.._.;:___:_ =::Prap. Lirtie _..__._.__._; <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......................... ----------- Date _-----_----..,-•..--•''---------- <br /> Septic Tank (Specify..Requirements) -----------........... --••------•-•--•-•...............•-•---•---.......:...... ...........................-•••-•-•----••. ........ <br /> •.i <br /> �.2 CNi <br /> )Disposal Field 1SpecifytRequirements] .. ................••---..._..........--•-.........•. <br /> F <br /> ......................................... ______________ -------------- <br /> {Draw existing and r ---- <br /> .:........... ..... ..- ._ - w. <br /> ,l g 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 taws, and Mules and Regulations of the San Joaquin Local Health District. Horne owner or liven- <br /> -sod agents signature certifies the following:. <br /> "I•certify that in the performance of the work for which this.permit Is issued, I shall not employ%any person in such manner <br /> as to become sub'Lct t;W mars`s C pensation laws of CaUfornia." <br /> Signed ----------------------------' -------= -------------L...... =......------ Owner <br /> ✓� <br /> 8Y ........................ ` ---------- ... = _-------------- <br /> ------------ <br /> ---------- Title ...._.. ...__......._.. .............. <br /> (If Ofher thanlI'•II owner) <br /> '1 FOR DEP TME E O Y <br /> APPLICATION ACCEPTED BY-•--•••--------- --------------------- ........ DATE _... <br /> BUILDING PERMM ISSUED;...---------------------- <br /> DATE. <br /> IiADDITIONAL COMMENTS°------------------------• ----------------------...................................................... <br /> r <br /> ............................................................I . •-__. _-_--_---.____.___--_-.•__ ----•_ __-_-•J -_-•--_.-- ---_..---------------------------------------------------------- <br /> - <br /> .--- _ .._.-------..---_--_---�__-_-_-••--•-._.___•-_- . <br /> ------------------- <br /> 1 A:.Fina; ...ate............ <br /> inspee--c- on by: ... .... ...................---••-----------••-••------••------- ----•--- = ` <br /> D .._/.0 --1'• •---------- --------• <br /> �� A SAN JOAQUIN LOCAL HEALTH DI ICT <br /> E. H. 9 1-'68 Rev, 5M:, i <br />