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FORlO_ff1Cl'USE: •-�"'`�� APPLICATION FOR SANITATION PERMIT . <br /> - ----------------------------------------------------- Permit No. <br /> (Complete in Triplicate) ' <br /> This Permit Expires-4 Year-From Date Issued Dote Issued <br /> ----- --- <br /> Il ------------------ <br /> Application is hereby made to the San JoaquiniLPcal 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 ----- 6---}.5-- - R. If�EA ---------------- SC =---------.CENSUS TRACT ----- ..------- <br /> Owner s Name -------------/-�Rl--F—--------SIV _- 1 7 ------------------------------------�- -------�P(hone Phone -939-75411 <br /> -----A—LI 7S--S-------.��'J=_N_A ;9!_1\ ------------------------------- City --- #�-SCR-La/tl.. t <br /> License # -------- --------------- Phone gv--7, c. <br /> Contractor's Name .--.... L41_l�l E -------_' �` f ` <br /> Installation will serve: Residence <br /> House Commercial ❑Trailer Court ;❑ 1 <br /> REPLACEMENT❑ = f <br /> DISTANCE TO NEAREST: Septic Tank /�� I Sewer Lines �.!:Pit Privy <br /> Water Supply. Public System and name ----- ---------------- ---------------------------------------------------------------------------------------Private,K <br /> Character of soil to a depth of 3 feet: Sand'F-] Silt Clay Peat Sand Loam Clay,Loam { <br /> Hardpan Adobe Fill Material-!_1�Q--- If yes,type -------------------------- <br /> (Plot <br /> ----:-_:.---- . � �y <br /> p ❑ ❑ Y ❑ ❑ Y ❑ Y <br /> (Plot plan, showing size of lot, location of system­ `relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepag pit permitted if public sewer is-available•\r.ithin 200 feet,) <br /> \ ----------------------------- -----•--------- - Li i <br /> ISN <br /> PACKAGE TREATMENT { ] SEPTIC TANK[ ] Sizequid Depth ----------- -:---- <br /> Capacity ------- ---- Type -----------•--- Material------------.---- No _Compartments <br /> i .,.�.:'3 I <br /> -- <br /> Distance to nearest: We—Len th-of-l------- � - 9p ----------------------_---- <br /> LEACHING -----�-------- <br /> / ---- - - --------- ------ <br /> LINE N <br /> y. <br /> [ ) a. :of Li es ' g each�.l.ine gun at�on� Total LenProp. <br /> th me -------------------- <br /> 'D' Box -----....... Type Filter Material ----- -------- ---Depth Filter-Material- ----------- ------1',41 'Q'stance to nearest: Well �'�__-_._: __Foundation"-^__:_._ _.---------- Property. Line ------- -------- <br /> - ,w. ti <br /> SEEPAGE PIT [ ] Depth .-.- !_ Diameters-.' - w_----- Number .-.----- "°---_-.------ Rock Filled Yes '[] No .ice <br /> -- --- -------------=----------1 •------ -�---Founda"tion. ---------------'--------------=- <br /> Water Table Depth Rock Size--_---- <br /> Distance to nearest,. Well --------------------------- • - ---. Prop. Line ------_-------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit # f' a Date ............ -------- <br /> Septic <br /> __-_-_ <br /> Se tic Tank (Specify Requirements) ------,P/ _._: -=: -----••-----7 , <br /> a F. t : 2 Ef_C1--- <br /> Disposal Field (Specify Requirements) --------------------------- -------------------------------- --- ;-------------------------- ------ --------------/---------- <br /> IINE------------3 - 50-4-J D --r— RTH--- x- 1y-------- --- <br /> - Roar-_-, <br /> , zz�f -. - -- -_._._ _.•_-_-..._:_�_ t. <br /> (Draw existing pnd required addition on reverse si�e) i <br /> I hereby certify that I have prepared this application and that the work will be done in(accordance with San Joaquin <br /> County Qrdinances, State Laws, and Rales-and Regulations of the San Joaquin Local Health Distrtit. 'Home owner or licen- <br /> sed agent`s signature certifies the following: . <br />` "I certify that in the performance of the work for which this permit is issued, 1 shall not employany person in such manner <br />� Y p p _ <br /> as to beta subject t orkma 's Compensation laws of California." > <br /> Signed [ ✓> '----------------------------------------- Owner <br /> �_ ,- <br /> BY - -------- - --- ---- ------------ ---------------' �� <br /> -" -�1-�• - Title -------------------- --------;--- r�.-- -I i----s_, <br /> (If other than owner) .-r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... - Q- -------- ---------------- }ATE c�J <br /> BUILDING- PERMIT--ISSUED-_-- =---- = = -- 4._-� ,:—w -_ - = --------- ------ 15ATE . �,_,�..--=---Wig :-----•--- <br /> ADDiTIONAL COMMENTS - i --- �- <br /> - ------- ----- - - ------------------------------------ <br /> --- __ <br /> ---------------------------------- <br /> -+ -- — r - <br /> Final Ins :ti ----- ------ - <br /> -------------- <br /> --_Date --- � � � ------------ <br /> ------------------ <br /> ------ --- <br /> SAN JOA UIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />