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<br /> f' FOR OFFICE USE: FOR OFFICE USE:
<br /> APPLICATION FOR SANITATION PERMIT
<br /> 3Permit No.
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<br /> (Complete in Tripiicatel ,.
<br /> Date Issucd..�:..�.�.....7 3
<br /> „•••.-••. This Permit Expires 1 Year From Date Issued
<br /> ,jF. •t„
<br /> .Application is hereby made to the Son Joaquin Locol Health District for a permit to construct and install the work herein described. ri
<br /> This application is made in compli-nce with County Ordinance No.549 and existing Rules and Regulations: t•
<br /> JOB ADDRESS/LOCATION............ S j- �.- -..... . .-:_CENSUS TRACT...__............ .. �
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<br /> - Owner's Name .... ........ . ... .. -.._...................... -- ...... ........-P one... .....
<br /> Addres's..._...... J'!''fG. ........................... ....... C ty. U�7 .. ...............Zi
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<br /> . .- .. /-
<br /> ..... ...License one . G�
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<br /> s ph �f:�� •�,
<br /> `ontroctor s Name.r.. l [.. .'� � .. r, •
<br /> Installation will serve: Residence [5eApartment House n Commercial ❑ Frailer Court ❑ i Ki.3;u
<br /> Motel ❑ Other.........
<br /> Number of.living units:....... ._._.Number of bedrooms......Garbage Grinder. ....Lot Size.-....... 'n..-.- - -#
<br /> Water Supply: Public System and name................. ............. ............-.-.-................................ ................_........
<br /> !- Privates
<br /> Character of soil to a depth of 3 feet: Sand ❑❑ Silt El Clay❑ Pea1y❑ ypandy Loam
<br /> Clay Loam❑
<br /> 1 Hardpan 0 Adobe Fill Material..... Ir es,t e.......... . r
<br /> • i _ __._ t�'c
<br /> [Plot pldn, showing size of lot, location of system in relation to wells, buildings,etc.must be placed on reverse side,]
<br /> 5 "4` NEIN.'If!ISTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) t
<br /> 'PACKAbE TREATMENT [ ] SEPTIC YANK € ] Size..................... .... :.:.:r...... ..............' Liquid Depth-.... .:_.. . .
<br /> , #... Capacity......... ........type......- ....:::: .....Material.... . .., ...... .{..,.No. Compartments...............,,..- ,
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<br /> oundatiori.............__.........Prop. Line...
<br /> I Distance to nearest: Well.. .......... *
<br /> LEACHl1 G LINE, j 1 No. of Lines.............................Len fin of each line. _....'..............:........Total Length .........--.........� t,
<br /> f 1 D' Box_..........,Y-ipe Filter Mot':rial ..... Depth Filter Material..........--".................... '.--.-,...... ....... j{
<br /> .......... .. ..... ' T' ..... Pro erty Line, -.........
<br /> 'Foundation;D1stanee to nearer!:Well...... ..........
<br /> ��i91':,;;;,.:f,t,•t��f�:r•_ s1 , _- _T__..
<br /> ! ..
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<br /> oR kFilled Yes
<br /> ... Number-SEEPA E PIT Depth. . .. .......Diametc...-.......
<br /> WaterTable Depth. ....... - .Rockglie........ . ........... .1 ......... a _[]
<br /> Line
<br /> o nearest; .................... ...... ......PrapFounrat�or�DistarcAet
<br /> N...
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<br /> REPAIR/AODITION�Rrev.-Sanitation-Permit#-_:_.:.. :.: :..-.._.Date._.. .... . ........ '------------- ] �s
<br /> Septic Yank' �ecify Requirements)....... ....... . `.". .....................
<br /> ` Ted-- r
<br /> Dlsposal.Field,[Speclfy ltegvuements -
<br /> 1 f .............................. .
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<br /> ,... p .. ............
<br /> 4 i {- `(Draw existing and required'add ition,on reverse isidej ( f =[
<br /> I horebjr certify that I have preprsrad•thisiappllcation aii44that`fhe Iwofk will ,be don@ in accordance with Sar Joaquin County a
<br /> =.; Ordlnaeces,- State Etaws, and:Ru!'�s 'find Regulations of theiSan Joaquin Lccol,Fiiilfh District, Homo owner ar licensed.agents '
<br /> <`>�signotutecertifies the' following, � ,�, '.
<br /> ryr "i certify that in the performance of_}he'work forT-w'hjc-this permit is issued, I shall!not am any persm, in such manner las 9-
<br /> , rk' 's Com ensation laws of California.';.. € 3
<br /> to become subject: to. P tx. '
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<br /> :Signed.r... i. .r................ . '7 — _ F.
<br /> .�............. . ....,... ..-. _Owner
<br /> �...v.' r r Title.-. ............
<br /> . .:...................._..........,..... -.-:,a,. .............. .... �. tie ..
<br /> 1t _
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<br /> I [If other thaniowner) I ! s.
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<br /> FOR 1 pE9ARTMEN7 USE ONLY OL
<br /> APPL'ICATON ACCEPTED BY:::'`'': --•'
<br /> _ ..... ..................DATE 1
<br /> 1 1...... y-.J... . .........:..... DATE....................... ..............
<br /> pIVISION OF LAND NUMBO-.-.A.'. - ........ ............
<br /> ADDITIONAL COMMENTS......................... ................................ .......:,..............,............ ........
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<br /> ...:. _ ........................ Da... f
<br /> ,{/ / �•.le�:-chi....•....... . . . . j
<br /> Y 12
<br /> Fina! Inspection byfl/ly -.f.r;�--y` .� •- W71677 REV.7/N
<br /> EH 13 s< { SAN JOAQUIN LOCAL HEALTH DISTRICT
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