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fQR OFFICE USE: <br /> ------ ...................................... APPLICATION FOR SANITATION PERMIT <br /> ....................................... (Complete its Triplicate) Permit No. Z,.,._l.2plo <br /> ...................................................... This Permit Expires I Year From D Doti Issued _.—!� 2�"i <br /> ato Issuml <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to construct and install the <br /> P� work heroin <br /> t <br /> Abed. This application Is made in compliance with Count Ordinance Na, 549 and existing Rules and Rogujotiqqs;, <br /> d- <br /> Pre ADDRESSAO"AT I ....0.3......... wWa,X,. CENSUS TRACT ............... <br /> ........... <br /> Owner's <br /> . . ....... ................. <br /> 'a Name ...... <br /> . ...... .........Phone <br /> cictrb - <br /> . . ..........City ........................ .............. <br /> ..... ........ <br /> :Co*Gct*r't Nome .. Aimnso # .J.. <br /> W,I&A 3., vffione <br /> !rts!pIIdtt*n will sewer <br /> Apo""NOM:13 CM,me a oTfql*Couft E) <br /> 4c"I E]Other.......... ............. <br /> ................. <br /> NuMber of living units,... ...... N Grinder Size <br /> Number of bedrooms <br /> Wa!er.Supply*,Public System area name ...... <br /> ....... ..... <br /> .............. <br /> ......... <br /> Chor000r of Slott - 0 <br /> !P!Qd pt�of V"tz .Sandal Wt 13 Ciay Sandy'"t Oj SO 4PM 0 CtGY Loom 13 <br /> C3 <br /> Hardpan Adobe a fill Matorial .............If .......... ..... ............. <br /> toM in <br /> !Plot plan, showing OZO of loti Joca <br /> !1oft,of Sys #r wells, buildings, ate. mutt be placed on 'revorse, <br /> M�QWA"TIOW (No optic tank or,seepage pit peMist <br /> Public,s.arwor is avallable,within 200 fact.) <br /> Liq Depth <br /> PACKAGE TREATMENT 11 SEPTIC TANK ............... um ..... .... <br /> C"Cit <br /> Type _ <br /> . .. . ..... <br /> M <br /> No. <br /> Distafte to nearest. Well ..... .......... ...... .....Foundation ndation,............ Prop.Line',z........ <br /> LEACHING LINE <br /> tentha .... ... .'Tota0 . tength <br /> . ............ <br /> V :Box ............. Typp filter IV�ptorlpl ....... <br /> Depth filter Materioll, ........ ........ <br /> Pis! 1P nearest; WO-11 ................. J Foundation ....... Property, <br /> SEEPAGE PIT Depth .......7.;�.......... 0101�6tor- ......... -Number .............. M... ... Rack Filled <br /> Y". <br /> Water Table. Depth ............ ........ <br /> . .Rack Size <br /> .... ............... <br /> Pistol"."neqlrlostt well. ............. .......... Pirop.. Line <br /> 411PAIR/ADDITIONIftv. Sanitation Perm## ............. .................. <br /> Date, ......... <br /> . ............ <br /> .;.Septic Tank'fSpecify Requirements). .................... ............... .................... .................................. <br /> Q;;p*�101 Field (Specify Requirements! ......................... <br /> ........ ............ <br /> ............. .......... <br /> ..................... ............... ........ ........ <br /> ................... ........ <br /> .................---------------------------------------------------------- <br /> .....•---•. ....... ....................,:..........•_..............._...... <br /> !Draw existing and required aid <br /> 41"w9r; reverse;idol <br /> I hereby certify that I have prepared this application and that �p work wNI be done In accordance with Sm. lid , <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Laval Healfh,DlstrlN Home <br /> Pr 4pw <br /> sed agents signature certifies the following: <br /> N certify that in the performance of the work for which this pen*t is issued, I net employ-any-pews" <br /> as to become subject to Workman's Compensation laws of Wifornla." <br /> Signed ...... Owner <br /> By ---------- -- <br /> iot e- -thc ftn_0 --------- Title ......... ....... .................. <br /> 0 R�IQPARMT'WNT USE ONLY <br /> APPLICATION ACCEPTED By _ <br /> ------------- ---- ---------- .... .. <br /> ------------------- ------ •- --------------------------------------- ------ ------------- ... DATE ........... ........................ <br /> BUILDING PERMIT'ISSUED . ;7.' <br /> ADDITIONAL COMMENTS ....____.......... <br /> ------------------ ---- <br /> ---- ------------------------------- ...... ------------- .........------................--I­/-. --- -- <br /> -- ------------------------- --- ---- ---- ------ I <br /> - ------------ --- ---- ---- -- ------ -- ----- -- ----------------­------- ------ - ­. <br /> ..................... ------ ....... <br /> Final Inspection by: ------- ... ........Date <br /> ReEH 13 2b 1-68 ... .... ---------- -------------- ..... --- --- ----------- ........... <br /> V/_ SAN JOAQ N LOCAL HEALTH DISTRICT 8/7h 3M <br />