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FOR OFFICE USE; <br /> %01" APPILICATION FOR SANITATION PERMIT <br /> V <br /> ........................... ....... <br /> (Complete In Triplicate) Permit No.;Wfir/,m9 <br /> A\ Date Is`su,hd.j&'.J47... .. <br /> This Permit <br /> Expires I Year From.-Date Issued <br /> Application is hereby made to.the Son Joaquin loco] Health District for <br /> a permit to construct and.install the work herein described:r <br /> This application is made in compliance with County/grdinance No. 549 and exist Qftles and Regulations.. <br /> JOB ADDRESS/LOCAJAON.__,_..�� <br /> .................... -........CENSUIS TRACT.................__...... <br /> ►Owner's Nome .... ... <br /> ­.. ................ .................. .. . ....... ....Phone........... .............. <br /> 7 <br /> 'Address...... <br /> . . . . .. ... ...........:.........City. .. . ...... ...zip----------------- <br /> ..........................Lice <br /> Contr*ctor's Ncime.. ... . . .. ... ... .. ... . <br /> ......... nse #.364 ---&...Phone.. <br /> Installation will serve, stes'lilence Apartment House❑ Commercial Trail r Curt C1 <br /> 41 �L J <br /> Motel ❑ Other.............................. ........... <br /> Number of living units:................Number of bedrooms............Garbage 'Grinder............Lot ize........ <br /> .......... .. <br /> Water Supply. Public System and name.......................:..............I......... ..................................I................ ....... ......... Priv <br /> • <br /> -Ch'aracter of sail to 6 depth of 3 feet <br /> Sand Silt[I Clay 0 Peat C) Sandy Loom 0 - Clay Loom 0 <br /> kardpon 'Adobe -. Fill Material.. .... _._.if yet,type............... .............. <br /> Plot plan,.showing size of lot, locatioVof t"Y'stern in relation to wells, buildings,,etc,must be placed on reverse side.] <br /> NEW INSTALI.AT' <br /> 1 . ION: (No 'septic t6nk or seepage ' it permitted if public sewer iiavallable within p ow , -n.2.00 feetj <br /> Liquid Depth.... ............. <br /> PACKAGE TREATMENT <br /> SEPTIC fANK Size .... .. ........... <br /> Compartments....... ..... ........4 <br /> Capacity. . <br /> Q06 <br /> pa f ...... <br /> k <br /> Distance-to nearest-.Well..._....- ..........-.-Foundation..... <br /> LEACHING LIN! X No. a n <br /> f Lines ...../.................Length q Vch fins. --------------Total Length <br /> Depth Filter Mote 101-1:17. .............................I....... <br /> 'IF 00 . e -.1 <br /> 'D' 9ox............Type Filter Material�qm.q�� rial......... -,10..e" <br /> Distance to nearest,WeIL-1:2V...............Foundation....Z.....................Property Line........ ........... .......... <br /> SEEPAGIL.PIT Depth...._.___.:��.Djameter....................Number.._......................._.._.. Rock Filled YesE] No <br /> Water Table Depth :. Rock Size.._....... <br /> .......... <br /> Distance <br /> to nearest:Well.........:.................................Founclotion......... .................Prop. Line.......... ................. <br /> REPAIR/ADDITION (Priw,Sanitation Peimit#................................... ...............Date.............._........I...... ........ <br /> SepticTank (Specify Requirements).............•-•-----•---•-----.......I.....-----..._-- ------- ..................................................................................... <br /> Disposal Field (Specify Requirements)`.:__.........:_.:. <br /> ................... ........................I-—................... <br /> ........................_...... ........Z:................... ";--------------------------------------------------------------------------------------- <br /> .................................................... ................................................I------------­­...................................I................ -­----------------- ........ <br /> ..J(Drow existing and required ad4i?ic;n on reverse side) <br /> 1 hereby certify that 1.haveprepared this application and that the work will be done In accordance with San Joaquin CountYy:� <br /> �i Ordinances, State Laws, and Rules 4ind Regulations. of the Son Joaquin Local Health District, Homo owner or licensed agents <br /> signature certifies the fallowing: <br /> .1 certify thgLin the performance of the work for which this permit Is Issued, I shall notemplo m y <br /> any person in such Tnonner as <br /> to fast ma u6 t o W45;)n's Comti laws of California." <br /> pensa on <br /> Sighed &q.... <br /> ...........V-- - ----Owner <br /> By----........... I.. .. . .........'Title.......... ............ ................... <br /> jif other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY................-1[*.. . ... . •--...-•-----.---............:.-•----._.......................DATE _------------_-- <br /> DIVISION OF LAND NUMBER.................�­­---------__........ ..................... ....... ..................................DATE_......_........._... ........:......- <br /> ADDITIONALCOMMENTS............:....... ..............--..•--------.............. --------------------------- ----------------------------------------------------------........... <br /> ..........I............................... --------------------------------------------- ..........-•-•----------••------•-----•---._.................... ......I .............:-1__.-...---1 ............ ................. <br /> r ...................:------ ------------- ..................... ........ ----------I..................................................... ...................... .......... <br /> Final,inspedion by:.._...._•--•--. .................. ­-------------................. ....Date 1` --------------L.-- <br /> Li <br /> ..... <br /> <i 13 24 SAN JOAQUIN LOCAL HEALTR DISTRICT MS 216" REV. ?/76 3m <br />