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FOR OFFICE USE: <br /> ------- --------12`-7?-;--Z-C)---- APPLICATION FOR SANITATION PERMIT <br /> ---- -------­ ''-------------------------- (Complete in Triplicate) Permit No. <br /> - <br /> -------------------------------- ----- ------ This Permit Expires I Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work <br /> -herein <br /> described. This application is made in cOmplionce with County Ordinance No. 549 and existing Rules an Regulations: <br /> JOB ADDRESS/LOCATION d <br /> -- ------A ---- -- ----- <br /> ZA,Q , r . -41- - ---------- <br /> Owner's Name --------�­CENSUS.TRACT­-------------- <br /> ------------------ <br /> ---------------------- -------- <br /> Address --- ---- --------------Phone <br /> ------------------- <br /> - --------------I--------- <br /> ......... city . <br /> Contractor's Name <br /> -------- ------- ----- <br /> --. - il tt-If I-"-I-------License # ---- Phone 4d <br /> Installation will serve- Rlesiden�e Apartment House-E].Commercial [:)Trailer Court <br /> Motel EJ Other----- <br /> Number of living units:____ -�7-------------- --------------------- VIS,. <br /> ---- Number of bedrooms ------------Garb'ag Grinder -- -- --- Lot Size <br /> name -L-ca--h ............... <br /> Water Supply: Public System and k <br /> Private <br /> '. �JSanclo SiltE] <br /> Character Of soil to a depth of 3 feet: --- -------- ------------S�7-1-�­­_-­------------------------------- <br /> '4; Clay 0 Peat❑D Sandy Loom -0 Clay Loam.0 <br /> ­.!Hardpan 0 _Adobe 39C Fill Material <br /> ------------ If yes, type ---------------------------- <br /> 0 <br /> %'14o wells, buildings, etc.. must be Placed on reverse side.) <br /> (Pl'ot plan, showing size of lot, location of system in relation <br /> fNo septic or seepage pit permitted NEW INSTALLATION I ttdd if pvblic sewer is available within-200 feet,] <br /> PACKAGE TREATMENTI I <br /> f I SEPTIC TANKf f Sizer---------j------------- Liquid Depth -------------------------- <br /> Capacity --- -- I------------ Type -------------------- Material <br /> ---------------------- No. Compartments <br /> Distance to nearest. Well '- 1 <br /> LEACHING LINE n -----------------Foundation ------------------ Prop. Line ----------- <br /> No. of Lines ---- -•-------•- -Length of each line------ <br /> --------------- Total Length -------- <br /> V Box ---------- T�pe Filter Material --' I -------------------- <br /> ----------t------Depth Filter Material <br /> .............I------- <br /> Distance to neareit: Well <br /> ------------------------ Foundation <br /> SEEPAGE PIT Depth -------------- Property Line ---- <br /> -------------------- <br /> Diameter ---------------- Number ----------------------------�Rock Filled Yes <br /> El No .0 <br /> Water Table:Depth <br /> --------- ----------1-----.Rock Size ---------- - <br /> --------------- ------- <br /> Distance to nearest. Well �-------------------- - - - Foundation --------- - I' <br /> ------------- ---- Prop. Line --------- <br /> -- <br /> REPAI t/ADDITION(Prev. Sanitation Permit ­-------I" ;---------- ---------- Date ----------- <br /> I' ----------- <br /> Septic Tank (Specify Requirements)i----- --------------------��# <br /> Disposal Field (Specify Requirements) ------- ----- --- - ----- <br /> --------------- ------------ <br /> - <br /> -- -:­Mei <br /> --------------/ -- -- <br /> ------------------ --------- ------------- f <br /> g --- ----- ---- ------ ---------------- <br /> I hereby certify that I have prepardthis' addition on reverse side)_4 <br /> -------- ---- ------ <br /> si e <br /> iraw-exis <br /> application and that the work will be do'ne 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 following: <br /> "I certify that in the performance of the-work for which this permit isissued, I shall not e <br /> as t bec e subject to L - . r mplay any Person in such manner <br /> I ork"th's o <br /> Cmpen ti.on'-ia-ws'c�t"cC'-Iiiornia.i, <br /> Signed --------I--- - ----- -""V }-[- t <br /> --- - ----- - ---- ---- ---- O,�,ner­ <br /> By - ------------ ---- t I <br /> i'Title- ---------- ----------- <br /> (if other than owner) -------- ------------------------------------- .............. <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- <br /> BUILDING PERMIT ISSUED -------------- - --------------------------------------------------. DATE --------- P74�`�- / <br /> ADDITIONAL COMMENTS -------------------------------- ------------------M--------------DATE -------- <br /> - --------------- ---- ----------------------------- <br /> -------------------------------------------------------------------------------------------L----------------- <br /> ----------------------------------------------------------------------------------- --- --------------------------------------- ---------- <br /> ------------------------------------------------------- - <br /> ------------------ <br /> --------------------------------------------------- <br /> ---------------------- <br /> ----------------------------------------L-------------------------------------------------- <br /> ------------------------------ <br /> - -------------------------------------- <br /> Final Inspection by. --0- ---------------- ---------- <br /> - iO;;_111 -- — ------ <br /> ----------------------------------------------------------------------------------------------------- <br /> - - - rDate ----�5- 77�_ie6-------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />