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FOR OFFICE USE: . ---4 <br /> 'APPLICATION- FOR SANITATION PERMIT t No. <br /> t , Permit ----- .71 <br /> -------------- ------24_5MW 11 <br /> (Complete in Triplicate) <br /> ----------------------------- Date Issued --- <br /> ------- t4r <br />---------------------- ___ 10. <br /> This Permit Expires I Year From Date Issued <br /> Application is hereby made to t4'San J.oaquin Local Health District for a permit to construct d install the work herein <br /> 'T <br /> described, This application is made in compliance with Courft Ordinanc No. 549 and ext ules and Regulations:' IVA C 0 ---------------------- EN US TRACT ---------------------- <br /> a <br /> EN U� T' <br /> SUS <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> City---- --- ----- .............. <br /> A _1� tni--e-Phone <br /> Owner's Name <br /> ---------- ------ - - --- ---- ----- -------------- .......................... <br /> -------- -1211) <br /> Address ----------- Ci <br /> --------------_------- <br /> Contractor's Name --- ---------- --- n icense # Phone --- <br /> Installation will serve: Residence•Apartment House C1 Commercial 17ra 1 ler Court <br /> Motel.r] Other ---------------------------------- --------- <br /> Number of living units:___.[_ Number of bedrooms .--A-----Gorba.ge Grinder ------------ Lot Size ------------------- ---- ------ <br /> Water Supply: Public System and n.6me ----------------------------------------------------------------------------------------------------------------Private Wr <br /> Character of soil to a depth of 3 feet: Sand 0 Silt(I Clay ❑ Peat El Sandy Loom E] Clay Loom <br /> Hardpan F] AdobejZ Fill Material ------------ If yes,type ----------------------------- <br /> (Plot plan, showing size of lot, loc i ation of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> rr <br /> NEW INSTALLATION: .(No septic tank or seepage pit permitted if public.5.ewer is available within 200 feet, <br /> PACKAGE TREATMENTSEPTIC TANK![ ] Size-------------------------------------------------- Liquid Depth .--------------------.---•- <br /> ' <br /> 7ial---------------------- No. Compartments ------_----_-- <br /> Capacity --- ---------------- <br /> - Type -------------------- Mciter <br /> Distance to nearest: Well --------------------------- --------Foundation ---------------------- Prop. Line -------------------,=- <br /> LEACHING LINE No. of Lines _----- -h of each line_ ---------------- Total Length ----1&................ <br /> ------------- Length <br /> 'D' Box ---- Type Filter Material W__9_d____Depth Filter Material ------ ------------_---- <br /> Line ------511/............ <br /> Distance to nearest: Well ------- Foundation -------------- Property <br /> ---- Number ------- -------------- Rock Fill6cl Yes No CC] <br /> SEEPAGE PIT Depth -------- Diameter A <br /> Rock Size <br /> Water Table Depth ----- <br /> Distance to nearest: Well.,:---/10V---------------------------Foundation ---------- Prop. Line ----------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- -- , --- <br /> ------ Date ---------------------------------- <br /> nts) - I-------------------- <br /> A � --------------- <br /> Septic Tank (Specify Requireme ----- --- --------- -------r-----` z <br /> s <br /> ----14�_ <br /> Disposal R ld (Specify Requirem-ents <br /> --------------------------------------------------------------- --------------------- ------ <br /> --------U_Q. V ------------------ -- - ------ ---------------------- <br /> - -- ----- -- <br /> -------------------- ----- - <br /> 9' <br /> I hereby certify that I have prepared this application and at the wor will be din accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or ficen- <br /> sea 'agents signature ceffl`fies7fhie46IIowin4: _W1 I <br /> "I certify that in the performance �f the work for which this permit is issued, I shall not employ any person in such manner <br /> i <br /> as to b;com ubject to WoOman'i Cora pA&sgtion laws of California." <br /> Signed -------------- --- Owner <br /> - <br /> ---= <br /> (If <br /> By ------------------------------------------------------------------------------------------------ Title --------------------------------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE -----77��7: --------- <br /> APPLICATIONACCEPTED BY -------------- - -------------------------------------------------------------------------------- DATE ------------------------------------------- <br /> BUILDING PERMIT ISSUED ------------IF -- --- --- - - ---------- DATE <br /> COMMENTS ---- ------4��-------------------- ---------------------- -------- <br /> -------------------- --------------------I-------------i------------------------------------------ ---------------------------------------- ------ ---------------------------------------- <br />{ <br /> -------------------I------------------- <br /> ------------------------------------------------------- ------------------------ -------------------------------------------- <br /> -------- ----- ---- ----- <br /> ------------------------------------ - - -------- -------------------------------------------- ------------------------------------------------------------ - ------- ....... <br /> FinalInspection by.. __­�------------------------- -------------------------------------------- ------------------------ Date <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />