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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> _421 — Per „t No <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- Date issued _1=16=67 <br /> This Permit Expires I Year From Date Issued <br />- -----------------------------------------:- <br /> ---------- <br /> AplSliedtion,js hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> descHbed. This application is made in complionce with County 0 dinance No. 549 and existing Rules and Regulations: <br /> -,Zj, -- ------- ---CENSUS TRACT -------------- ------- <br /> T A ---------- --- <br /> JOB ADDRESS/LOCA ------------------------ ----------------------- <br /> __P One <br /> Owner's Name ----- ------ --------------- <br /> ly <br /> C't ---------- <br /> Address—_;�,7V/z/----- -- - <br /> Contractor's Name ------ -- - -------- <br /> ... ... -License Phone one ------------------------------ <br /> Instatilation will serve: esidenceXApartment House,E] Commercial :F <br /> ]Trailer Court <br /> •#w' Motel F-1 Other -------------- ---------------------------- <br /> 4/ --------- <br /> Number of living units:____-/ <br /> f --- Garba 7 Gjnder ------------ Lot Size <br /> N6mber of ms -r- <br /> ------------------------------------------------Private El <br /> Water Supply.. Public System end name ra, <br /> ,yi-t: Clay E <br /> Character of soil to a depth of 3-feet.. Sand'[] e ilt[I Peat❑ Sandy Loam 0 Clay Loam E] <br /> Hardpan El ! ,.-A, clobe Fill Material ------------ if yes,type ---------------------------- <br /> (Plot� plan, showing size of lot, location of systerr� in relation to wells, buildings, etc. must be placed on reverse s cle. <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> ---- <br /> PACKAGE TREATMENT SEPTIC TANK![ Size------------------------------------------------ Liquid Depth ---------------------- <br /> a. , f Compartments ----------------- <br /> Capacity --- ------------ Ty :------------ Material---------------------- No. <br /> i, P� <br /> Distance to nearest.. Well -----------------------------------Foundation _.-------------------- Prop. Line ---.-----•-•-----•---- <br /> --- <br /> LEACHING LINE [ ] No. of:Lines ----=--------- ---- Length of each line_.--------------------------- Total Length <br /> -D' Box --------*---- Type. Filter Material --------------------Depth Filter Material --------------•-------------------------- <br /> Distance toynearest- Well ---I-------------------- Foundation ------------------------ Property Line. ___.------ ----------- <br /> YL) Nd Ej <br /> SEEPAGE PIT Depth -------------------- Diameter ----------- --- <br /> ----- Number -------- -------------- - Rock Filled es <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> -------- <br /> Distance to nearest. Well - --------------------------------------Foundation ------- ----- <br /> Prop. Line ----------- --------- <br /> - - I ----------------- Date ----------------------- ---------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- <br /> �ts) -------- --- ------------- <br /> Septic Tank (Specify Requir6mei I ----I--------------------------------------------------- ----- -- ---------- <br /> 2. <br /> 0_6----- <br /> Disposal Field.(§pe fy_E:eguirements) --- - -------- <br /> ----------------------------------------------- ----------- ----------- <br /> ---- ------- ---------------------- -------- ------------- ------------------------------- <br /> f— - - ____ ------------------------------ <br /> --------------- ------------------------- ------ -------- --- <br /> ---_---s-1 d-'e) <br /> (Drd\�existing and required addition <br /> pify that 1 hereby cerI have prepared this application and that the work will be done in accordance with Son Joaquin <br /> t <br /> i <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or..I.ican- <br /> sed agents signature certifies the following: ' in such manner <br /> +tom ' "'I certify that in the performan of the wo kfor which this permit is issued, I shall not employ any person <br /> , a to bec su je to VV*k 's Comp) sat. n laws of a ' rnia." <br /> ----- <br /> Signed -.7 ---------- <br /> ner <br /> By ---- --------------- -------------- - --- itle -- ------------- -------------- ---------------- - <br /> f-i-If other thb� A owner <br /> DEPARTMENT USE ONLY <br /> IN DATE�7 / ------------------- <br /> APPLICATION ACCEPTED BY ----- ------0��---�N---------------------------------------- <br /> BUILDINGPERM IT"ISSUED ------------4-----------------------------------"---------- ------------- --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -- <br /> ----- -- -_A7----------- <br /> ------------------------------------------ ---- :-_-�------W------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------ <br /> --------------------------------------------------------- --------- --------------------------------------------------------------------------------------------------------------------- <br /> - <br /> - <br /> - <br /> -- --I--- --- - <br /> Final Inspection by: - ----- ----------------- ------------------------------------------ ------- ------- -Date <br /> SAN JOAOUIN LOCAL-HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />