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` - ••-;APPLICATION FOR SANITATION PERMIT <br /> :......._� ..................... . ..f.;........... 1Z! ; {Coenpietntn Triplicate) <br /> Permit No. Z .:;7�-0 <br /> .... <br /> This Permit Expires 1 Year From Data Issued Date issued <br /> Application Is hereby made to the San Joaquin Local Health Distrkt for a permit to constrict and Install the work herein <br /> described. This application Is made In compliance with County Ordin nce No. 549 and existing Rules and Regulationst <br /> 4 11 <br /> JOB ADDRESS/ T . .. . �� <br /> �-- ��t NSUS TRA <br /> Owner's Name a s <n., P., ��. .... . ... .. .t.".c�rY.. 1.'.. .. .........Phone 496 <br /> Address ..._.. .. _.... ...............Ci/y .. .��'d ' -. ........ <br /> Contractor's Name ............. �........_.......................................License# .......................... Phone ....... <br /> Installation will serve, Residencefi�Apartment House❑ Commercial pTroller Court [1 <br /> f _ Motel❑Other............ .............................. € <br /> Numof Iivir g unite: ..:Number of Bedroom . r ...Garbage"Giindlot`Sire:. ................. :�- 3*.:... <br /> Water Supply: Public System+ and name <br /> ................ i ...................._......._.. ....................•-.-..... <br /> .Private <br /> Characterof soil toodepthof 3 feet: Sand SiltCClay O Peat SandyLoam ❑ Claytoam i <br /> Hardpan p Adobe Q Fill Materlal ............If yes.type............... ............. <br /> (Plot plan, showing size of lot, location of system in#relation to wells, buildings, etr_ must be placed on reverse side.) <br /> NEW INSTALLATIONe (No septic tank or sae aj it,permitted if public se Is available within 210 feet.I <br /> �� fj" 6 <br /> PACKAGE TREATMENT ( ] SEPTIC TANK] h /J S€ze. ia Liquid" Depth <br /> ---...... .. ....... ..................... <br /> capacity . - Type _ aierial..�C..a.'�Y. ...... No Compartments .. <br /> ' k Distance to nearest: 'Well ._ ilk ,� ...............Foundation .�� � ,... Prop. Line..- ......� <br /> .EACHiNG LINE Na. of Ei .......... Length each I ne. � ....- Total Length ... ... ......... <br /> 'D' Box :3 �..... / !i ....... �... ...... <br /> Type Filter Malted pth Filter terla! ./r .. <br /> Distance.to neare:t,_Weil- -,� �. t Foundat on_ ..,...... Property Llne .. <br /> SEEPAGE PIT [ } Depth .... ............ Diameter ......... ...................................................................... <br /> Size ................................ <br /> -Distance to nearest, Well ........ . ...........................Foundation .................... Prop. Line . <br /> REPAIR/ADDITIONtProv. Sanitation Permit# ................if_....................__.. Date .................................. <br /> F Septic Tank ZSpecify Requirements) .......................... ......................................................................... . .. <br /> ©isnosal Field (Specify Requirements) .............. .......................................................................;. .........f.._.....--.---...�............................-•- <br /> --......... . ----•.............................•................ ....................__............................................................... o <br /> ............................... .. _............................................e)....................._........�:......... '......; <br /> (Draw existing and required addition on reverse sld <br /> ! I hereby certify that I hove prepared this application and that the work will bo done In anordana-lidolt Sara <br /> Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or liven• <br /> sed agents signature certifies the following: <br /> "I certify that In the performance of the work for whlch�this permit Is Issued, I shall not employ any person In such manner <br /> -- ens fo dc-" - su if`ta W kmo "Compen`sption�IdAwdsl,S:gnec! . ............. Owner <br /> oe <br /> ---.... .By ..........--•-----.........------• ....... . ritte .......................................................`. .. ........ <br /> If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....- LAC. ... ....... �s DATE ' <br /> BUILDING PERMIT ISSUED ....... lttr_.r41- .. .... . .... <br /> I ADDITIONAL COMMENTS ..% . .... ...` ^. .. .DA >.:. :,..,_:...... :' <br /> 7.�-... r_ - ��................... ... .... <br /> -------------------------------------- . ...........................ors�n ' ....................... <br /> ............ ............................................... _ <br /> ...". <br /> Final Inspection by. ---... � . <br /> ....._-_.... Date ..�� <br /> y. .. <br /> ER 13 2h 1-68 Rev. 5M SAN JOAO INl LOCAL HEALTH DISTRICT , $/7h 3M <br />