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d <br /> OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> . -^ ..,., fPermit No: <br /> .� �- .� .� <br /> - (Complete in Triplicate) <br /> ------------------------------------- <br /> ,� From Datetlssue,,,,,, Date Issued <br /> ---------- ---------------------- ----------------------- <br /> This Permit ExP ires i.Year d j <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 tiompliance with Cou Ordinance No. a+ and existing Rules and Regulations: <br /> ------------CENSUS TRACT `S -------------- <br /> JOB ADDRESS/LOCATI N .���j --�D--�---0'-�1--�-- ---- -, I <br /> Owner's Name ., "' F 7 ¢' /- --------!-------------------- Phone _ r' <br /> b l��•� Q <br /> ., t ... <br /> �$'� city AOA_1MPO---------�t -`------------------------------ <br /> Address -------------------------�*� �° I <br /> Cont`ractor's Names--A.---- rr'-_�'_ AS4------I---. �---------- !---License#��0 /f PhaneL <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court 0 � <br /> ' Motel ❑ Other �°_q�-C ----- �`t f <br /> f <br /> r - - - <br /> t V � ►S� <br /> Number of living units: ._ -_ Number of bedrooms_ _ F <br /> t�)�- •, �.���GarbageGrinder ________-._'Lot Size -- _--------""__-- ----- - <br /> Ye ------------------------------------ <br /> t <br /> -- , s �.� r Sand Loam Private <br /> Water Supply. Public System and name ..-------- ------------- <br /> El <br /> Character of soil to a depth of 3 feet: Sand'❑t, .Silt'❑�.Clay Peat❑ y ❑ Clay Loam <br /> i '❑ .Fill Material ______"_____ IfYes,type ------------ --------------Hardpan ❑ AdobeW <br /> � <br /> (Plot plan;sliowi`ng"size'of`iot,'location•of-system- in-relation-t8 well ,- buildings,-etc.-must.�be..�played on reverse side.) <br /> 4. seepage pit permitted if public sewer is available\within 200 feet,) <br /> NEW INSTALLATION: (No septic tank or 4� I� <br /> PACKAGE TREATMENT SEPTIC TANK Size_ 40-6 �a� ...--Z.__�Liqu�d Depth------------- ----- <br /> Capacity,2 <br /> _00-64L Type p Cn �;57�- -- Material. -- No.� Compartments ---------- -•-- <br /> ' Distance to nearest: Welles---- Q--____-----------------Foundation _5 ------------ prop. Line .__ ._______- <br /> LEACHING LINE; [ ] No.'of Lines -� -- _. ----- Length of peach line--- <br /> ---------------- Tota) Length ------ ------------- <br /> 'D' Box �_0N__ Type Filter Material)" X �_ =___.Depth Filter Material _IQCJGK,__"-------------�-- - <br /> k Distance to nearest: Well ---(6-0------------- Foundation ��7- ------------- Property Line _. > -------=---- <br /> X'� <br /> SEEPAGE PIT De tl ` ----- Diameter Number __� - ------ Rock fired Yes No 0 <br /> Water Tablei3epth ------f�Q--------------- ----------�-{tock Size'- --�------�-�--------- <br /> - 430 .---------- <br /> //4) - ` <br /> Distance to nearest: Well ------ - ---------------- ---Foundation ProQ. line _..------- . <br /> OVAIRIADOT40N(Prev. Sanitation Permit# -------- ------------------------------ - Date -.------"---k----- --------------- i <br /> I. <br /> 'Septic Tank (Specify Requirements)• ---------------- ----------- --------- ---- ----- - ---- <br /> r r <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------ ------------------------------------ <br /> ► -gid ----------- ------------=---_---------{------------------------------------ ------------------------ <br /> ------------ -------------------------------------------- <br /> I <br /> ---------------------- <br /> -----------------------------------_----------------------------- = ---------------- <br /> i(Draw existing-anF required addition.on reverse side) <br /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, .and Rules and,Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the followino: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subje o Work can's Compfriscition laws of California." ; <br /> � p� L - - -�"� <br /> - itle SignedOwner <br /> T <br /> -- --- - - - - ----- - -------------------BY 4------ <br /> Of , <br /> s <br /> other than owner) <br /> ' FOR .D.EPA T USE ONLY ' <br /> APPLICATION ACCEPTED BY .- s -- ----------- ---- - --- --- -- --------- - -------# DATE -------- -- -------------- <br /> �._�_� DATE <br /> BUILDING PERMIT ISSUED -------------------------- ----------------------------- <br /> ------------- <br /> ADDITIONAL <br /> - -------------- " <br /> ---------------- <br /> ADDITIONAL C_OMMENTS ------------ --------------------------------------- ----=------------- <br /> ------------------------ -------------------------------------------------------------------------------------------------------------------------------------- <br /> I <br /> I <br /> } <br /> f - ------- ----� --- <br /> -- ------ -- <br /> ----------------------- <br /> Final Inspection by: - ---------------------------------.Date = <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />