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tFOR OFFICE USE: .
<br /> APPLICATION FOR SANITATION PERMIT
<br /> a
<br /> AComNele in4riplicate) a Permit No.
<br /> ............................... ...... r 1
<br /> ti
<br /> ................. This Permit Expires I Year From Date Issued Date Issued 3 ..........
<br /> Application is hereby made to the San Joaquin�Loccil Health District for a
<br /> described. This appplication is c in compli6he`elwith County Ordinance No. 540and exisermit to ting Rulestalndthe work Regulatiops=rein
<br /> JOB ADbRE56/LOCATION .._..... -s
<br /> r _. .. CENSUS TRACTI...........i -/ ......... . .......
<br /> ' Owner's Name .... ` $7y
<br /> .. ........... ....... Phone 'e-
<br /> Addressf7
<br /> .........:..._.......a *tlG .... { ... .
<br /> ......................Gjt ,.. )
<br /> y ...
<br /> .........................................
<br /> ontractor's Name ........................ .....''
<br /> ' - 2- -.... ._...t.. -----.. ......................:.License# ................. ... Phone ..............................
<br /> Installation will serve: Residehce ❑Adartment House 0 Commerci I ❑Traile�Jr
<br /> Motel ❑Other v°�'Ci.................
<br /> S�
<br /> ' Number of living units::..,..:'. . Numb'te�arry-of bred ooms .-._......._Garbage Grinder . ...-...... Lot Size ...
<br /> I 6x1 �.. y{...............................
<br /> Water Supply: Public System and nam . . ....._. �/
<br /> .......................I........ ...._............ ....I........................ . . ..................Private .
<br /> Character of soil to o depth of 3 feet Sand[� ilt❑ Clay ❑ peat Sand Loarnr
<br /> ' t t ❑ Y ❑ Clay Loam ❑
<br /> Hardpgn 1 �iAdobe ❑ Fill Material Ifyes type ............................
<br /> (Plot plan, showing size of lot, location of systems relation to wells, buildings, etc. must be placed on reverse side.)
<br /> tNEW INSTALLATION: (No septic tank or s�`pa ;pit`�permlgt if public sewer is available within 200 feet')
<br /> PACKAGE TREATMENT ( ] SEPTIC TANK �f�X '�s �'.. YOc. a.L4r ( f
<br /> Liquid p �.�y�.......
<br /> ' Ca acity �_ y T �,-�4S erial.... s1 :`,..• No. Compartments
<br /> Y 'r y,Pe o-. C ....
<br /> istance to nearest:\We)l .,.. . ...:......................Foundation ... .... Prop, tine .........,... -A
<br /> LEACHING LINE No. of Linesn �( ., Len of _ 07otal Length
<br /> "i� N
<br /> 'D' Box ._. ` r M L.
<br /> ' Type Filter Mbtenal ..y-,- 3=,.._Depth Filter Material / p y
<br /> Distance�to'nearest: Welles ..: _ VF t]on 6:K:11- /0....... Property tine
<br /> SEEPAGE PIT / ...""
<br /> [ti Depths'"/Y r Diameter, u/� r!....,...� / _
<br /> - ...0 ! '"" � , -���" ry`�.., y.•--.. .... Ro/ck Filfed Yes No Q
<br /> F ' Water Table l Depth ,p.tl..!{� --':-'Rock Rock Size ,.....(0.�7/..e.,.....
<br /> Distance to nearest: Well y+� `+': Foundationy,rw.,/.U. . Prop. Line .... ..
<br /> .�..... ..
<br /> ' REPAIR/ADDITION(Prev. Sanitation Permit�# .......... �.. )
<br /> Septic Tank (Specify Requirements)�.... ............ ... ....1....�.- --- --
<br /> Dis osol Field (Specify Requirements) .......... 1.....I................2 ..............,................
<br /> .,:
<br /> ............ 1..._..... ....... ................P......s............. 0.......'•..:.... 1
<br /> )Dra'w existing c ri�'i�, rd uuired addition e e)f
<br /> '1 hereby certify that 1 have re orad this applicaNOsi
<br /> woon reversrl and'fhat the work will be done in accordance with San Joaquin
<br /> County Ordinances, Stale Laws, and Mules and Regulations of the San Joaquin local Health District. Home owner or licen•�
<br /> sed agents signature certifies the following: f.. 1, ',
<br /> "Icertify„thi5t in_the.performance of the work.fo it this Is rmit,is issuedV i shall ne(employ any person in such manner
<br /> fo become u o Wor man a CenlponsahonJiaws of California" I
<br /> Signed ..... .- Owner
<br /> ............... .......
<br /> .` ................................
<br /> ry .... :.............
<br /> ffi _
<br /> ....................[Title
<br /> ...............er than owher) .......
<br /> DE M
<br /> USE ORIL
<br /> JAPPLICATBUILD( A CO MENTS . r T t `� - ..........-
<br /> < f 7 r. !.. ` - EATE(DATE
<br /> It
<br /> BUILDING PER -MIT ISSUED . ..-.. ... .` .' �® .. ... . .. .�.�.E�:.::_. :%j�.. . ...:..5':�•iis. '...;:..' ...�C• pyc.
<br /> ION ACCEPTED BY ......
<br /> 1�.. . m.., . .p , . .,.,. . _,.,..._....
<br /> �.. �..a�........
<br /> ::.:::............... . . ......... . .. . .
<br /> incl Inspection by: ........ �`---'•C�f .._...
<br /> . ......,i .- --_._... . -to -
<br /> ...............................
<br /> ..,...................� 1...,.-,...,....
<br /> ,. ._............................ � ✓ III
<br /> A 4U1N�,40Cd5L?�;HEA�7H;}0
<br /> en /- q.. .
<br /> H, 13 241-,1$ Rev 5M.
<br />
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