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OR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _4---------2_4 <br /> ---------------------------------------------- <br /> Date Issued <br /> --------------- VThis Permit Expires I Year From Date Issued <br /> ------------------------------- -------- <br /> Application is hereby made to the San JoaqUin Local Health District for a permit to construct and install,`the work herein <br /> described. This application is made in compliance with County Ordinance No 49 and existing Rules and X <br /> Regulations: <br /> V <br /> -------------------------- <br /> JOB ADDRESS/LOCATIO ------------- <br /> -4�g- ......CENSUS TRACT <br /> ------------ Ph <br /> 4 <br /> --------------------------------------- <br /> Owner's Name ------- z2. -------Z:�',......... <br /> Address ------jc:�: ---- -- -- --- --40-9 -------- city <br /> ------License one/ <br /> Contractor's Name ---------- - --- - --- ---------el<------ - --------------------- <br /> Installation will serve.. Residence P<Partment House-[] Commercial []Trailer Court '0 <br /> MotelF-1 Other -------------------------------------------- <br /> ,0'1,-- V I <br /> Iro Ws arbage Gri WO Lot Size ---•-•-- <br /> Number of living units:_'_ Number _nd pcler - --------57 <br /> ----------- ------------Private El <br /> Water Supply: Public-System and name ------ <br /> Character of soil to a depth of 3 feet.. Sand'[] Silt E] Clay Peat E] Sandy oam 0 Clay,Loam El <br /> Hardpan E] Adobe' Fill Material &0----- if Yes,type ---------------------------- <br /> (Plbf plan, sH.owing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) - <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is,available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC-TANKf ]-v -- : t_ Siie--------------- - _7 - <br /> ---------------- ------------ Liquid Depth 1---------- <br /> % ------- --- <br /> Capacity ---------------------- Type -------------------- Material---------------------- No.; Compartments ------------ <br /> Di-Istance to nearest: Well ------------------------------------Foundation ----------- ---------- Prop. Line;--------- ------ ,-�1 <br /> 1w , � <br /> k LEACHING <br /> ine .--------------------- <br /> LEACHING LINE Nb. of Lines ------------------------ Length of each line_________---.--____..__--__ total Length ------_------------_------ <br /> 'D' Box <br /> ---------- Type Filter Material --------------------Depth Filter Material -------------------------- -------------­ <br /> Diitance to nearest: Well ----------- ---------- Foundation -----------------------!,Property Line --I--------•------------ <br /> ---'SEEPAGE PIT Depth --------- ------- -bicin�efer t,Number 777777777='r-A-l�ock Filled Yes' No C3 <br /> Water Table Dept ----------------------------- ------------Rock Size -------------------------------- i <br /> -4.............. ------------ ------- <br /> ...-Foundation ------ Prop. Line <br /> Distance to nearest:'Well -------------------------------------- - <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------- ----------------------------------- Date ---------------------_-- ------- <br /> Septic Tank (Specify Requirements) ------------------- ----------------------------- -------------- -- ---------------- <br /> Disposal Id ! <br /> posa F')e {Specify Requirements) ------- <br /> d7 ----- -- <br /> - <br /> ----------- -------/-- _ _-v------ <br /> ----------------- <br /> i---------------------------I----------------------- <br /> --------------- ---------------- --------- ---------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse 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 Rule's and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in th performi5picq of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become,," to W Co risation laws of California." I <br /> Signed ------ -—Owner <br /> T le --- A----------- <br /> By -------------------------------- - -------- ------ ------------------------ - it ------------------------------- <br /> (If othe an ow er( <br /> FOR DEPARTMENT ENT USE ONLY <br /> APPLICATION ACCEPTED BY !)X ----- --------------------------------------------------------- DATi -----------,- <br /> ---- <br /> PERMITISSUED ------------------------------------------ ---------------------------------------------- --------------DATE -------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------/----- --------------------------------------------------------- ------------------------------------------- <br /> -------------------------------------------- ---- ----------------------------------------------- --- -----------------i--------------------------------------------- <br /> -------------------------------------------- --------------- ------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------- <br /> ----------------- --- ------------\------- ----- - - - - <br /> -- --------------------------------------- ------------------------ ------------ -- ----1 _ C <br /> Final Inspection by: ... Date ------------ --------------------------- <br /> ------- -- ------------- ------------------------------------------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev.5M. <br />