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.............................................. APPLICATION FOR SANITATION PERMIT <br /> ... .............................................. <br /> .. Permit(complete In Triplicate) y <br /> No. ..7....- . _ .. <br /> This Permit Expires 1 Year From Date Issued Date Issued.••`•-�? 77 <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to cons and Install the work heroin <br /> described. This application Is made In compliance with County Ordinance No., A9 an exi ti Rules and Regulatoro: <br /> -- -- <br /> / ...�......... k..� CF.R............CENSUS TRACT .............:.: y.....: <br /> JOB AOORESS/LOCATIOIJ..................._.. ... . q <br /> Owner's Nome .......... ........................................ ....................... .........Phone .. �r. ..�� L... <br /> .............................Address ...................... A/1 .......................... City ..._: <br /> . � l4 <br /> Controcfar's Name ....... ..... ............................... _.._. <br /> Phono e?31.'.�. <br /> Installation will serve, Residence❑Apartment House Q Commercial❑Traller CoW <br /> JR. <br /> Motel❑Other......... .........--------------•---------- _/ .4 C-- <br /> Number of living units:... Number of bedrooms .........---Garbage Grinder ............ Lot Size ...-ld._---------- ............. <br /> Water Supply: Public System and name ............................... --..-.....--•--•....w.------.............. ----..... ..........--....Private/9 <br /> Character of soil to a depth of 3 feet: Sand Q Silt[3 Clay ❑. Pet!,Q Sandy Loam day Loom ❑ <br /> Hardpan❑ Adobe❑ Fill Material............. If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENTSEPTICTdNK; Size.... <br /> �`. .... liquid Depth ................... <br /> ( ] ) <br /> Capadty ............... . . Type -------------------- Material................ ...... No. Compartments ..., ............A <br /> Distance to nearest: Well Foundation ........... .......... Prop. Line .................. <br /> D' Box ............ Type Filter Material ....................De Depth aTraI . Length £ <br /> LEACHING LINE Distance Ito nearest: Well ....... <br /> . - Length of each ...... epi ..Fitt,._...._. _..__.._. <br /> [ I g � � <br /> ' yp p .Filter Material .....�....':.:............................� <br /> � <br /> ....... Foundation .r.................... Property Line .................... <br /> ...� <br /> SEEPAGE PIT ( ( Depth .................... Diameter ....,.......... Number ..................._....... Rock Filled Yes [3 No <br /> Q <br /> Distance to nearest= Well ..........................................II Size .t..-........--.-.-.............p <br /> Water Table Depth ............ .... .... i. <br /> 11 <br /> P Foundation ................... Prop. Line ........._...__. <br /> REPAIR/ADDITION(Prov. Sanitation Permit# .-..................!..( .-.............--.. Date ............. .. ...............1 <br /> Septic Tank (Spadfy Requirements) .......... lf✓P.........'rr! L ..... -::' .._ �f T - _........__........_.... <br /> Disposal Field (Specify Requirements) 1 1.L.Z�- �1..:-.. ...�......... ...... -.1........:�........-•..... ........ <br /> ................A.............•----..._•----......................._.....................:r . .... .......6!.:f.F..�.....A..W...Y.Y..:.-._. .. L. <br /> ...................................................-------- -•--................................-----'•---._..........................................................._.._........................... <br /> (Draw existing and required addition on rbverse side) <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Jeavivin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Man- <br /> sed agents signature certifies the following: <br /> "1 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 subject 1 kman' mpe salon laws of California." <br /> Signed ....4a..1 `.... ... ........... ................................. Owner <br /> By ._.. .............................................................................................................. title _.... -.. _....................................... <br /> (If other than owner) <br /> FORMEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ................ ... .. <br /> .. ... .............. ............................................... DATE ... ....-...._-�7................ <br /> BUILDING PERMIT ISSUED ..................................................... ..................................................DATE - . ..................................... <br /> . <br /> ADDITIONALCOMMENTS ............................................ ...... ............._....-.................... ................................................... <br /> _..... ......................---..................................................................................._..... .................................................. <br /> ............__............................... ... ...--.................. . ............................._...-...... . . . .................. .....__................................... .... <br /> ........... .... ..................... .. .. ............ . ..... <br /> 7 <br /> Final Inspection b ..... ..................................I.............Date ..... -..�.. <br /> EN 13 24 1-68 Rov. 9 SAN JOAQUIN L L HEALTH DISTRICT 8�7h 3H <br />