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<br /> FILE COPY
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<br /> T � � FOR OFFICI: USE.
<br /> APPLICATION FOR SANITATION PERMIT
<br /> kY i
<br /> P
<br /> +i I' ermit No. ....7. .: .�__L
<br /> .. ..........................
<br /> (Comp(s1a in'Triplicate) +'
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<br /> y� This Porrnit Expires f Year from Qale Issued
<br /> Date Issued.......:.......:...L. ;.
<br /> s"!Applrotion'ls hereby.made to the San:oaquin Local Health Distri;t for a permit to constrict and install the work herein
<br /> described This
<br /> :a is made in compliance with County Ordinance No. F,49 and existing Rules and Regulations:
<br /> t J013 �>,DDRESS./L N .,/:7_ ,.2.... t..!SfC.X. �b ..:. ....- CENSUS TRACT"
<br /> w;�hN•. .�.2v
<br /> "r'Ownef-s,Narne = /
<br /> N ,t7 yr " �sl>t x'-................... ............ ' .....................Phone .F. .�r r
<br /> :. . �.
<br /> • :..? Addret�s+ :.1 l� ...: r1 r�'Pr....5 .......... ................City .._. x :<__..----.-__._........__-_-..-._............
<br /> .:'
<br /> Can*r Dar s Name)
<br /> 4, me
<br /> A ! � ---.License #.,7,C.fi/.7...7Phone _�.
<br /> „ �. ;
<br /> fnstollutlon wl!!serve Residence El Apartment House 0 Commercial R�Trailer Court��] �
<br /> %;'At
<br /> �i€ ` ". !{ ;Motel U Other_.......... SNunit
<br /> a....
<br /> mirer•of hving units]liA.,.. Number of b rooms A,1,t_✓..Garbage Grinder tr_...__ Lot Size
<br /> `tear �Cw �. . a
<br /> Woter':5uppiy PublicSysrem and name ti•fi- _ ( .,�c- ��__.. .
<br /> ........................
<br /> ![ .: ... ..................Private( •r.
<br /> Charachsr of sail to a depth of 3 feet: Sand r`Slit 0 Clay 0 Peat❑ Sandy Loam fl Clay loam �
<br /> IIr, � .......,:r•: wt��a,
<br /> : Hardpan❑ _Adobe CFFill Material . if type---------•--------------
<br /> y
<br /> {piotplan„'aiowing size of lot,'location of system in relation to wells, buildings, etc. must he placed on reverse side.)
<br /> .NEW INSTALLATION::,I_�(No septic tank or seepage pit permitted if public sewer is availoble within 200 feet,)
<br /> ;rS,E.PTIC TANK -... ._...t
<br /> yQ-�__._._ ••.PAClrAGE TRFATMI-NT Liquid Depth
<br /> �
<br /> '� � _ enc•. Capacity� Qv,..6ALT e = Materiai.._ 't�--cNo.. C� p , .._._._....--
<br /> YP �a C_1
<br /> r 4I :is stance:to.,nearest: Well •,1 .�...............Faundatian .../.G._.�.... . Promeli a_...75'..:-----------
<br /> 6
<br /> ......
<br /> 1 s c + a. p.
<br /> r
<br /> :LEA CHtl�IG LINE ;"No of Linen 1......:...... Length lof each: line.. -._,&I-C! -Total Length, ...o e.-r-..
<br /> Box' (� , Type Filter Matertal,.�F..1i�. _ .
<br /> DB
<br /> 's v �;�w �- •rq-r .�„ .._._Depth Filter Mat=rial�..- I,P..'�..:.:___._' " -•'
<br /> t
<br /> i ti� a� •s4 :}f e'i Distan•e w »oarest. Wel .J* ............ Foun_dation .... ' Pro ey Lne ... 3 r -•--
<br /> lry
<br /> s re SE:PAGE AT
<br /> Depth , :�; Diameter Number . ._/.................... Rock Filled Yes ,�C "No
<br /> Y�r`� .WaterTable.D•p * ' Rock Size. 1
<br /> th .........T'Q......
<br /> Distance to nearest: Well .._..-/Va................. e� io ./g r i
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<br /> ndaf' nr Prop_t,L nB ....LS~`
<br /> EDSelptic.x,s�ni
<br /> REPAIR/ADDITION(Prev.Sanitation Permii t —Date
<br /> e . fk (Spcuy�Rme
<br /> „
<br /> sposaiFeld ,SpecifyWRequirements} ...... -...—............... ...__...... .........
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<br /> .. ...... ......................................... ,
<br /> .. ...............................................I--•---•---•.........................................._............_..._._.__. ................. ....... .M' t
<br /> (Draw existing and required addition on reverse side[ }
<br /> [ hereby"'certify that I'have prepared this application and that the work will be done in accordance with Sant Joaquin
<br /> +� Counly.:Ordinances, State Laws,and Rules and Regulations of the San Joaquin Local Health District. Hoene owner ar,licen-
<br /> �49 `sitd agents sigznture certifies the
<br /> following:
<br /> 1,cartify.that in the performance of the work for which this permit is issued I shall not employ
<br /> P Y an y person in such manner
<br /> ' ias-to become-subject to Workman's Compensation Laws of California."
<br /> ' Signed '
<br /> -•-- ..............................
<br /> ........_. ................. Owner
<br /> f .
<br /> 5
<br /> BY,,' + s >fl;ran
<br /> ",e...._..._.._-.. 'Title ............owned--
<br /> FOR DEPARTMENT USE ONLY
<br /> APPLICATION ACCEPTED BY -ries,
<br /> n ?.,. 'r .............................••--................................. DATE.1-_31_ 11....... .
<br /> "BU7.
<br /> ILG[NGtPER.lAlT ISSUED.
<br /> ..........
<br /> AQQtTIrJNAL COMMENTS R * � ...... ...----..... ............DATE............................ E'�
<br /> . .
<br /> a
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<br /> ..;....._.-..::_.: ............... ..........................�..--._,._........_............... ...........-_......---...... ..
<br /> Final Inspection by:_ ..�?,Y ? D _,...j �' ....
<br /> s . �. .... ...
<br /> Y..
<br /> ..
<br /> r � ...... at ae._ ...U.._.._ _...
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C '
<br /> i k ;.�E tt 9 1 d8 Rev.5M 6.
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