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FOR OFFICE USE: <br /> F ------ --------- ------------------ ------------ APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ------ ---I------------------------ --------------------- (Complete iN Triplicate) <br /> -------- ------------------------- --------------- This Permit Expires I Year From Dot' Issued <br /> e Date Issued ---//7L <br /> Application is hereby made to the San Joaquin Local Health <br /> District for a permit to construct and install the work herein <br /> described. This application is made incompliance with County Ordinance No. 549 and existing Rules and Regulations:' <br /> _57p - ----------CENSUS TRACT _�D <br /> JOB ADDRESS/LOCAT N I- _.F efe <br /> p <br /> ----- - <br /> ------------ - <br /> Owner's Name OL <br /> ------- — -------P <br /> hone _Fa_Address - L - - 2 <br /> ? - -------11-1 City <br /> - <br /> -------------------------------- <br /> -------- <br /> - <br /> Contractor's Name ----------------------------------License Phone _gAa-v� <br /> Installation will serve. Residence A6GTIY <br /> partment House-E] Commercicd ElTraller Court ❑ <br /> Motel ❑ <br /> Other <br /> Number of living units:------ N'umber of bedrooms <br /> ..............Garba-ge Grinder ------------ Lot Size <br /> ___________ <br /> Water Supply, Public System and .name ----5MA '_� <br /> I . I [C <br /> Character of soil tofeet: <br /> ---- ------ -- ❑ <br /> --- ---------------------Pri vote <br /> 4 -,r- 0 <br /> Ae Pt�'Of 3 f eet: SandK Silt 0 <br /> Clay El Peat El Sandy Loam <br /> T=rdpZW� Ado�beEl FT4�M <br /> Clay Loam El <br /> Hardpan E] Adobe E] F4 Rc�te_riaf <br /> --- y e-s,t y�pe <br /> Mot plan, showing size of lot, loc-ation of system in <br /> A relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION:" (No sepfl6'tank or seep it permitted if p <br /> W6P bljc sewer is available within 200 feet,) <br /> PACKAGE TREATMENT <br /> SEPTi�TANK f <br /> Size---- <br /> ---- ---�7- -------- Liquid Depth --------------- <br /> Ca po6 ty ------ Type f-10 q---- eP� a4_� <br /> rV__ __ <br /> �M, <br /> - ----------- No. Compartments ----------- <br /> Distance to nearest: Well -----------67-6--1------------Foundation ------ <br /> LEACHING LINE. - f ------ Prop. Line --- <br /> No. of I Lines ------------------------ Length of each line----------.----------------- Total Length ------ --------------------- <br /> 'D' Box .----'------ Type Filter Mater I ____________________Depth Filter Ma erial <br /> --------------------w----------------------- <br /> Distance to nearest: Well ------------- --------- Foundation --------------------- -- Property Line <br /> SEEPAGE PIT ------------ <br /> ----------- <br /> Depth ------ ------------ Diameter ----- --------- Number ------------------------- -- Rock Filled -yes ❑ No <br /> Water Table Depth ----------------------- ------------------------Rock Size ------------ --- <br /> - <br /> Distance to nearest: Well --------------- --------------------:_-.__Foundatio6 ------ e <br /> I -- , . ----------- Prop. Lin ...................­.. <br /> REPAIR/ADDITION(Prev, Sanitation Permit# -----:------------- -------------------- Date -------------------- <br /> ----------- <br /> Septic Tank.-(Specify� Requirements) --------------------------------I <br /> ------------------ <br /> -----------------------------------------I----------------- <br /> Disposal Field (Specify Requirements) -------- !7,7 -1-J -C <br /> V_��----------- //et, j /------------/P - <br /> --------- <br /> ----- - <br /> ----------------- --------------------------------------I-------------------------------------------------------------------------- ----------------------; <br /> --------------- --- ----- - ----- ---- <br /> --- - ---- - <br /> - -- <br /> ---------------------- <br /> -- - -- ----- ------ <br /> (Draw existing and required addition on-reverse-side) -- --- --- -----I------- ----------- <br /> I hereby certify that I have pr e-p ai'r'e'0 this"application a6d"th at! the work will be done in accordance with Son )ciaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the followinq: <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 sub'ect to orkman's Compensation laws of California." <br /> Signe --------------------- -------------------------------------- Owner <br /> suo' <br /> By ----- '_--- ------ ------ <br /> ------------------------------------------ Title <br /> (111f other than own <br /> a �w <br /> FOR DEPARTMENT USE ONLY <br /> T I <br /> By <br /> 4. <br /> APPLICATION ACCEPTED BY------- ---- <br /> A_ <br /> APPLICATION ca .. ..t .... .......... <br /> ---------------------------------------------------------------------------------- DATE --- <br /> BUILDING PERMIT ISSUED -- -- ------- --- -/--c-------- <br /> ----------- <br /> --------------------- <br /> ADDITIONAL COMMENTS _F---------------------------------------------------------- DATE ------------------------------- ------- <br /> ---------- <br /> ------------------------------------------I------------------------------------------------------------------ <br /> -----------------------�'7- ----------- ------- --------- -- -------- ------------------------- ------- ------- <br /> ---------------------- ------------;� ­----------------------------------- -------------------------------- <br /> ----------------- <br /> --- ---- --------------- ------ ----------------------I----------------------------------------------- <br />- <br /> -----------------------4----------- <br /> Final Inspectio - -------- ------ L-- - ------ <br /> �.. - - --------- ---------------- - <br /> -------- <br /> -- <br /> ----------- <br /> by--: <br /> - --------- --------------------------------- ate -----/./__~_-/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />