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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ti <br /> -- --- --------------------------------------------------- Permit No. -2 <br /> (Complete in Triplicate) <br /> ---------=------------------- --------------------------- <br /> ___:�� � <br /> --------------------------------------------------------- This Permit Expires 1 Year from Date Issued bate Issued Td. <br /> 1I <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 -.----.----.---------------------- <br /> .__CENSUS TRACT . - ;� .__-____ <br /> Owner's Name --- �-_} Q=:S.�oif1/---------- __..--_--- <br /> Address ,o_S '`L.._�'- ,4 :---------------- <br /> . .City.. �N-GI _----------------------------------- <br /> _ 1�0�� <br /> Contractor's Name -------------- - ] =License # _ � Phone 3 �. <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court TI <br /> Motel ❑ Other . _ 4X_'_----_�P_ = <br /> Number of living units: - Number of bedrooms Y-------Garbage Grinder _~._ Lot Size __ 1 - _______________ <br /> Water Supply: Public System and name ___________________ ___ ___ _____________ ____Private ®-� <br /> ) <br /> Character of soil to a depth of 3 feet: Sand' Silt F]� Clay [] Peat El Sandy Loam -E] Clay Loam El <br /> Hardpan E] Ad''obe ❑ . Fill Material------------- If yes, type --------------------- <br /> (Plot pian, showing size of lot, location of system ih <br /> relation to wells, buildings, etc. must be placed on reverse side.) {,3 <br /> NEW INSTALLATION: (No septic ANK:14-11- <br /> or seepage pit permitted if pub is sewer is available within 200 feet,) d <br /> PACKAGE TREATMENT [ ] SEI 'Size__ -_1 !___X ----------- Liquid Depth T_ _________________ <br /> Capacity �W____ Type- -- MaterialP,-� No. Compartments �................ v <br /> , �� i �, <br /> Distance,to- nearest: Well_________________ __`Foundaton �_________ Prop, Line_:�—/ <br /> Disfance,to- <br /> LEACHING LINE No. of Lines __. _��ength of each line L Total Length� Q-______________ <br /> Type Filter Matena <br /> b Box _ _ l _ ___ Depth Filter Material _ _ --------------------------------- <br /> iY S � i f <br /> Distance to nearest: Well _> E------------- Foundation -/P..........k Property Line.-___.-.__..____ <br /> i 33 <br /> SEEPAGE PIT [ ] Depth -- ___I---------------Diameter'' _ -------------- Number ----------------------- ____iRock Filled Yes Q No Q <br /> Water Tible Dep --- ---~`--- .--w----------------------- --Rock Size, ------ <br /> Distance to nearest: Well --------t----------•----------------[...Foundation - `-____-- Prop. Line --------._..--.---_--- <br /> 's 1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------?--- ----------------------- Date ------------------------------- -) <br /> i F <br /> Septic Tank (Specify Requiremenfi€) ---- ------------ --------�; --'j-• ---------q---T---i7------------------------ <br /> -I <br /> ;i <br /> --------------------------------- <br /> 4 <br /> �k <br /> Disposal Field (Specify Requiments) ------------------------------ <br /> R <br /> :. , , _ _ <br /> ------------------------- ------ ---- ---=------------------------------------- <br /> � (Draw existing and requiredad8itioiii,on reverse-side)­4 w Y` - - KK=- - __--�-•-� ��-Y----- <br /> I hereby certify that I have prepbred this application and�tliat the work will be done` in accordance with San .Joaquin <br /> County Ordinances, State Laws, and Rules and'Re �atians of tf�e San .Joaquin Local He althF District. Nome owner or licen- <br /> �. I <br /> sed agents signature certifies the following: z1. <br /> "I certify that in the performanceioi the work for which this ermif� is issued, Fshall not imp oy any person in such manner <br /> as to become subject to Workma s'Com ens t+.on laws of C lifo `i <br /> g� r <br /> Signed _ : i! 'Owner , <br /> t r <br /> ! - Title � / �yQ - � -------- <br /> ------------------- <br /> By ------ -------- --- -------------------- { '*,'_. <br /> (if other than o <br /> FOR DEPARTMENT LJSE bNL'Y- <br /> APPLICATION ACCEPTED BY _t__ _C--- p4S i "N`_-------------- (-�-� " " °.~ - ATE -----�J--"I7--7Q--------- <br /> C DATE _____ <br /> BUILDING PERMIT ISSUED -------------------------------- T- - =' <br /> ADDITIONAL COMMENT '/ -----�2*^te-r ". ' � '`s'" _ ' <br /> -----`�' <br /> `�` ` / !lam - <br /> _______________________________________________�Y_�1.J�.J...,�.t___=�e_.�__m...=______ __r__-.__:__-----___----__-____________._____,_____.._ ,..i____ ------------------------------------------ <br /> --- - - -------- /F _ ___-. . ... -�..__. .. ----------_ _ .. .. 1 P_`_Y ____ <br /> aal Inspection by: ----- --- ------ '��_ - -- ----------------------------------- ----------------------- - -''Y.Date ---`3`:- ---- -------------------•---- <br /> __ SAN.JOAQUIN LOCAL.,HEALTH•_DISTRICT�,,,,. <br /> 1-'68 Rev. 5M <br />