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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ...........­­........ ........... <br /> Permit No. <br /> (Complete In Triplicate) <br />. ........................... <br /> Dote issued .... <br /> .........I.......................... This Permit Expires I Year From Date Issued <br /> Applicbtion is hereby made to this San Joaquin Local Health'District for a permit to construct and install the work herein <br /> described. This application it made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ... .9QQ/­ ... .......0 KR :..T V.&....•... ..................CENSUS TRACT <br /> Owner's Nome ... .......1K. ...............Phone............................... <br /> .............T................ <br /> X.. <br /> Address 0�2/......S.......CA. ............................ city ....................__.0.4........................................... <br /> ----- ....... ... ... .. ... ..... <br /> r*s Nome <br /> License # .........�:� .......... Phone ........................ <br /> tZ. ..5;=..S <br /> Contractor's .......)......... <br /> Installation will serve: Residence 0 Apartment House 0 Commercial-OTraller Couri- <br /> Q <br /> Motel E]Other --- ................. ...... <br /> .............. <br /> Numbt�r, f living units=.._..._......... Number of bedrooms _.. ..... Grinder N-0-__ Lot Size .......... N <br /> Water Supply: Public System and name .............................. .......................................... ........ .......... ................Private <br /> NJ <br /> Character of soil'to-b depth of 3 feeti -Sand Silt E] tiaPeal Sandy Loom 0 Clay Loom <br /> HardponjB' Adobe-[j Fill Material _ .................. <br /> �'(Plbt plan, showing size of'tot,--locotion-of-,system--In-relatio n-ta-weil s,_buildings, etc. must be placed on reverse side.) <br /> N 0 <br /> -NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available-within 200 feet,[f-PACKAGE TREATMENT SEPTIC TANK Size. / ke9hl..,_...... Liquid Depth,,_,..,�................... <br /> Capacity ....... Type Fgf�K65T Material. rt <br /> Compaments <br /> f........ <br /> -Distance to nearest: Well; ...............Foundation ..... Prop. Line ...... <br /> LEACHING LINE No. of Lines ........./...........L. Length of each line....... ........... Total Length <br /> V Box ...—..?Tjpe Filter Material ACU--Depth Filter Material ...... ,'2__._....... r <br /> Distance to nearest, Well ... Foundation ..Ie�..:7t...... Property Line -��.................... <br /> 7 <br /> Depth—, .........-Diarn te _R�ck_F_111eid_:-Wis 8"No 0 <br /> SEEPAGE Pl�,kl <br /> Water- ble.,,Depth........ ..Rock Size Ta 17111�).....::L <br /> -. <br /> Distance to nearest: Well ..................... . ................Foundatio ropkLIA <br /> REPAIR ADDITION(Prev. Sanitation Permit# ...................__........6............ Dote ......................�,�A <br /> Septic Tank (Specify�Requirements .......... ...........*............................................ ............. <br /> DisposalField (Specify Requirements) .......... .................. ...................................... ................................................... <br /> .............................m........... ....... .......... .............................................. <br /> -------- ------------- --------- .............. .'------------- ----- ------- ----- " " ...................... . . <br /> g -- q - '--- i ' <br /> (Draw <br /> existindreuiredadditionon onreverse <br /> 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 Sion Joaquin Local Health District. Hom* Owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify into performance 64 the work far which this pernflt1s.issued, Lshall-hot employ any person in-such manner <br /> as to be a sub ict to W r, man;.Com sation laws of Callfainla. <br /> ... ......I <br /> Signed ....... .......... ................. .............. Owner <br /> I V. <br /> By .............................. ............t`k.D. Title .............................................. 12........ <br /> . ....... .. ............. <br /> (if other_thon'ownor).Z_1------------------- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....... ...................................... ...............7....... ....... ....... DATE......... ... . .................... <br /> BUILDING PERMIT ISSUED ..............................I._......................... ...DATE ... ......... ----------------- <br /> ADDITIONALCOMMENTS .......................................................................................................... .................. N........... ......... <br /> • <br /> ............ . ..... .. .....I . ..........r...................I................................I..................................... <br /> "H:5 I.v/\ 11 ----•------ <br /> . .. ....... ....... ...............;!.......................... ....../...... <br /> ................................. .. . ........ -------- <br /> Y ... . . . .. .... ......................................... ....... ........ <br /> ...... .......... <br /> C, <br /> . ...............---------- ... ................... .... ....... <br /> Final ... ... ............... ........................... <br /> nal lnsp�ctlon.I V. . .. . .. .......SAN JOAQUI.N AOCAL HEALTH DISTRICT <br /> E. H.1-3 24 1.'68-Rev. SM 7/72 3-X <br />