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'I OR OFFICE USE. APPLICATION FOR SANITATION PERMIT <br /> i <br />...... ....................................•--•.. 6 <br /> (Complete in Triplicate) Permit No. .. ....•.............. <br /> ........ This Permit Expires 1 Year From Date Issued Date Issued ... ............. <br /> Application is hereby made to the Son 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 8-. �r!�- ' / __....._..CENSUS TRACT ................. . .. <br /> / �- �.Phone� a .a....... <br /> ,. _ � ... ._...--- p•� , <br /> Y. _ ... <br /> gcic3ress _ �1i :�: C+ty' 27c1:....... :i°:.. t <br /> Contractor s Nofiie :. , : + = lC, /.. .. <br /> f <br /> Installationwill=serve-� �.-4:.Re'sidence,-fZ-Apartment Houseo,Comm'ercial ❑Tfailer£ourt ok. <br /> Motel',•❑'Other ... j.... s <br /> Number of liv+ng units;• - .. Number,.of. bectrooms._ _ _.Garba"ge Grinder ..Lo#Slze ��� � `.' <br /> V gter Supply Public System and Ad-me: I?r►vate , <br /> Character of soil to a depth.of 3 feel. Sand❑: Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 4 Clay Loam ❑ <br /> Hatdpah ❑ Adobe Fill Material If yes,type <br /> t <br /> . •yon. aes , auldings, .et .. us , �e.: lcedon `revse.side�(P]ot plan,_shpwing,siie.of. lot,.location,.of,.system in,relatmer <br /> NEW 1NSTALL4TION; (No septic tank or seep` a pit permitted if,pvbirc sewer1s available within 2b4 feet,._- <br /> :._ <br /> PACKAGE;TREATMENT. ( ) SEPTIC TANK-( Size. _�C S Liquid Depth <br /> + type': ��� �.: Mdterial----..___..... __ No. Corn attments ..... <br /> Capacity -- .Yp .�- - .�. .. <br /> Distance to nearest Well 4-c __ .. Foundation 9 __ _ Prop Line .. <br /> LEACHING LINE [ No. 64"1. .. Leng#h ovacl .... Potal Lengtf� <br /> D' Box -- - Ty{�e Filtei :7Vlateriai ': �f K Depth E ilMe`Mafierfal"` .lr�:ff ° ... ' <br /> Distance tq-nedrest: Well .:r :. .: Fotrndatiorr" Property Line .....:; ! <br /> SI+EPA0E PIT-'Depth- P•_.�.. Diameter -•Number' «1 Rock'•Filled 1 Na b <br /> ! Water. Table._Depth; .. . .,�.-. Rock.Si e., ;:.•.-.. .. <br /> E Distance tonearest }Well ... Founda'tion . _i Prop Lane ` <br /> REPAIR/ADDITION{Prey. Sanitation'Permit .. Data ,-. <br /> jSepfic TankSpecify 'Requirement)' - - ._ ...... - <br /> Disposal Field (Speeify Requirements) . : .. -•- .................... : -- ----•-•-- - --•--- -• ... ---- <br /> :•• - <br /> i <br /> . _ ....... _ ------------------­------- _ ___ .. <br /> } ;(Draw existing and required addi#ion on reverse side) I i <br /> I Hereby certify that I have prepared this application and that the;virorkrvAll 6e done�t in'•accoidance wrath;Son: Joaquin <br /> County Ordinance's; State Laws, and Rulei"and Regvlafirons of tiie S¢r+ Joaqu+n Local'Hetiith District Home owhe `'or'licen <br />_ � f s <br /> sed agents signature ceMfies.the..following:. •• <br /> "I:Certify that in tha peiforritianee of the;work for which this permit is iss red,'I shall not employ any person in such ma <br /> nnars <br /> as to become subje:t'Vf- "Wo`r tin's`Co'rnpensat:on <br /> Signed = r _: ===,.1•_:_ } .. <br /> BY L ..... '' ----------- - - •3.itl ... <br /> e <br /> 5 (If other than owner) <br /> � ; E ONLY; <br /> '•� � � � <br /> F FbR DEPARTMENT' USE <br /> APPLICATION ACCEPTED BY ... � _- --- HIwl1D DdTE _ . $ . ,!- <br /> BIi WING„PERAA °.ISSUED ` =' , .. _ :�_ f < :D;41 E"_j r •. <br /> COMIUII:NTS --- _ -- ._. . ...... _, f ,� E t ... ------ <br /> ADDITIONALI y <br /> ... .. .. .. .. .i..._ .. .-_ }_ a- . .i.....: ....5.... .�..._ _�--. .._. .. .�...:. .. _Y <br /> t S. 3 <br /> t r Date d'__ ' t <br /> Final lris ectior b L . t.- ti•.:.... _...., r, t. •,• <br /> =SAN JOAQUIN dALL. <br /> SFIFALTH;�DISRI f �� s <br /> r. u 13 24 _-An o_1' sAs 7/72 3 M <br />