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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> � 7/� Q ` (Complete in Triplicate) <br /> tDate issued <br /> ------------------ This Permit Expires 1 Year From Date Issued <br /> ------------ --- struct and install the work herein <br /> Application is hZrreby made to the Son Joaquin Local I Health District for a permit to con <br /> described. This application is made in compliance with County ordinance No. 5,49 and existing Rules and Regulations <br /> --------CENSUS TRACT -------------------- <br /> -------------------- <br /> --------------- ------- <br /> JION -------------- --- - - - -�s <br /> JOB ADDRESS/LOCI ZIM--.6 D---- <br /> Owner's <br /> Phone ------------ -*--------------- <br /> Owner Is Name 1-0--------- - ------ <br /> - <br /> �e q-- --------------------------------- ...... <br /> Cityc <br /> Z---------- -- V-111 q- ------ Z <br /> --- ---- Phone ----------- <br /> Address ------� Z4-) ------------------ <br /> --------Licens.4 <br /> Contractor's Name -------- -------- -- - <br /> Installation will serve-. 'Residence Apartment House-D Commercial snTrailer Court 'El <br /> Motel []Other -----h ------- <br /> I Lot Size <br /> Number of living units:--- Number of bedrooms -,- <br /> -----__--___.Garbage Grinder ------------ --- ....Private <br /> --------------------------------------------- <br /> Water Supply: Public System and name ----------------------•--------t I - Peat E] Sandy Loom ❑ Clay,Loam .0 <br /> Character of soil to a depth of 3 feet: Sand'[] Silt Clay!,El #1 <br /> / ------------ If yes,type -------------------------- <br /> I Hardpan E] Adobe! Fill MatFrial— <br /> ells, buildings, etc. must be place4 on reverse side.) <br /> (plot plan, showing size of lot, location of sy'stem in relation to w t \4, <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size-------------------------------------------- <br /> F - <br /> --- Liquid Depth -------- <br /> ... .... <br /> -------- rt <br /> ------------- No. Compartments . <br /> Capacity --------------------------------- Type -------------------- Material <br /> Distance to nearest. Well ------------------------------ -----Foundation ---------------------- Prop. Line ---------------- ------- <br /> LEACHING LINE No. of Lines --------------- -------- Length of each line---------------------------- Total Length 1, ----------------------------- <br /> % I Material --------------------Depth Filter Material ---------------------------- --------------- <br /> 'D' Box -- --------- Type Filter <br /> y-Lihe ---------- ------------- <br /> Distance to nearest: Well- Foundation ----------z------Properl <br /> No 0 <br /> Rock Filled Yes ❑ <br /> SEEPAGE�'011-4� Depth -------------------- Diameter ---------------- Number -.------------------- <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Foundation --------------- .... Prop. Line <br /> Distance to nearest; Well ---------------- ------------------ <br /> t <br /> REPAIR/ADDITION(Prev. Sanitation Perrnit# ---------------------------- <br /> ---------------- Date ----------------------- ---------- <br /> ----------- - ---- --- <br /> ------ -------------- ------- <br /> --------------------- <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify, Requirements) <br /> P----------------------------------------------------------------------------------------------- <br /> ------ ----------------- ---------- ---------- 01------------------------------------------- I <br /> --------------------------------------------------------------------------------------------------------------I----------------- <br /> ------------ ----------- ---------- -------------------------------,--- ide) <br /> (Drawlexisting and required addition on reverse s <br /> I I Joaquin. <br /> 1 hereby certify that I have prepared this. application and that the work will he done in accordance with Son <br /> County Ordinances, State Laws, and Rulel and Regulations of the Son Joaquin Local Health District. Home owner or IiiiiIII; <br /> sed agents signature certifies the following: <br /> "I certify that in the perform nce of the work for which this permit is issued, I shall not employ any person in such manner <br /> � r <br /> astobftmesublipctt Wlo man,sjcoi� ation laws of California." <br /> O <br /> Sign -- ------ caner <br /> - <br /> -------------------------------- --- ---------------- <br /> Title ---- -- <br /> By --- ------------------------------- -- ------------ <br /> ----------- - <br /> (if other tha owner')', -N7-,(,rur. <br /> -.rte, <br /> 14 FOR <br /> R DePAMENT USE ONLY <br /> --------------- <br /> ----------------------- <br /> --- ----------------------- <br /> CEPTE <br /> APPLICATION AC EPT D'IBY - ------------------------------------- ------------------- - ----------DATE ------------------------------------------- <br /> BUILDING PERMIT ISSUED ----------------- ---------------------------------------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------- <br /> -------------------------- <br /> t <br /> ----- -------------------------------------------------------- --------------------- --------------------- -----------I <br /> --------------------------------------------------------------------- ------ -------------------------------------- ---------------------------------- <br /> ----- - ---------- ------t----l--�;--(-- <br /> --•_------'--•_-_- <br /> - <br /> -.---------------------------- <br /> ----------- <br /> - <br /> - ---- ---- ----- --- ------- ----------------------------------------------- -ate ---- krl-- <br /> --- - - D <br /> Final Inspection by: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />