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FOR OFFICE USE: , APPLICATION FOR SANITATION PERMIT <br /> i� 5 Permit No... } <br /> (Complete in Triplicate) <br /> Date Issued <br /> ` -- ----------- <br /> This Permit Expires I Year From Date Issued <br /> } <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> L,4 <br /> -- <br /> M ---------CENSUS TRACT <br /> JOB ADDRESS/LOCATION ._ <br /> -- <br /> --..Phone---------------- <br /> iv. <br /> Owner's Name <br /> ---=------------ <br /> A I z# 1 - - - --------- <br /> Address ------- city h <br /> ---------------- ---=-------- - -- <br /> - ---------- -- <br /> aH <br /> Contractor's Name .._ . --------- <br /> -__ _-_. icense #- -- ""?.- ------- P <br /> - -------- ----- -- - -- <br /> ❑ Commercial ❑Trailer Court <br /> Installation will se ve: Residence Apartment House I <br /> �} Mote! ❑ Other ---------------- <br /> �� A <br /> Number of living nits: l <br /> ..__ Number! of bedrooms --�.___---Garbage G�nd r I U-_--_ Lot ize --_ <br /> ' ------------------ ------ diva et <br /> 1 Cia`y' Peat Q Sandy Loam ❑ CIaY <br /> Water Supply: Public Sy to��and name _-'�__ _________ <br /> �� � t r , <br /> Character of soil to a deNDp h of 3 feet: Sand ❑ Silt y ,Loam ❑ <br /> Ha pan + ►da t Fill Material If yes, type ; <br /> (Plot plan, showing size of Iot, location of system inlrelatioon lto wells,buildings—etc:must be placed on reverse side.) <br /> 9 4111 <br /> r1.. <br /> NEW INSTALLATION: (N 'Septic tank�r-seepage-pit-perm•itted-if-•public-sewer-is.ovallablewithin 200�feet;f"—""— <br /> PACKAGE TREATMENT [ SEPTIC TANK [ ] Size--------------------------- /`-------. Liquid Depth ------------------------- <br /> -------------------- <br /> ----- <br /> --------------- <br /> ___ f -" No. Com artments ________________ __ <br /> �apacitY -------------------- TYpe -------� Material � rPl <br /> pistance to nearest-.,Well.- Y----- •__ '== ---=:_Xou_ndation�_4t,__ -----Prop. Line -----_---- \ ' <br /> -' I . Len th of%each line._ _ - ----- -6_ Total Length ---------------------------- <br /> I <br /> _---- -•---- V <br /> [ ] of Lines -- ---------- -- - 9,; ---t ,� - - - � v <br /> r �' " 0jI De'th"�'Filter Material�� Y <br /> LEACHING LINE NO.Box ---------_-- Type Filter M'cit&i6j _-'-•-------------- p -------•----------- <br /> I <br /> 'Distance to nearest: Well ------.------------�•Foundat•ion� ' ------_ Property Line ------------------•--• <br /> ------- <br /> I <br /> SEEPAGE PIT [ � Depth Diameter _ Number ---------------------------- Rock Filled Yes ❑ No I❑ <br /> --------------- -- - - <br /> # ----------------Rock Size ------;------------------------ <br /> Water Table Depth�------------------------------- <br /> _. = t , <br /> Y '' Distance to nearest: Well ------_ ----------- �------- Foundation -------------------- Prop_ Line ---------•----------• <br /> ----------- <br /> i ----------- Date --------- ---------------------I <br /> REPAIR/ADDITION(Prev. Sanitation Permit#�____--_- - - <br /> /lc��vF7' T 4/-K------- <br /> Septic Tank (Specify Requirements) `_- .-__-I-- 0- ------ w <br /> _- +.c-_//_._--- t --------------- <br /> Disposal Field (Specify Requirements) _____- --�-Q`-'--- <br /> ---------- <br /> ------------------ <br /> ------------- <br /> ------------------------------------------ <br /> ------------------------------------------ ----------------------------------------------------------------------------------------------- <br /> ------ ---- - ------------------------------------------------------------------------- <br /> --- ---------- - -------------------------------------------- --------`--------" <br /> on reverse side. <br /> I hereby certifythat 1 have prepared this application a d tharthe work will,be done in accordance with San Joaquin <br /> ` (Draw existin and required addition <br /> 1. p p <br /> t County Ordinances, State Laws, and Rules and Regulations_of the San Joaquin Local Health Distiict`Home owner or (sten- <br /> k ' sedagents signature certifies the following: <br /> 1 "1 certW <br /> rmance of the work f which this permit'is issued, I shall not employ any person in such manner <br /> as to borkman' om ens on laws of California.' <br /> p <br /> Owner <br /> Signed - - - - -- ----- -- r . <br /> BY ------ i • ---------------- Title ---- ------------------ --- -. n owner) I ' <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> - ------ ----------------------------- DATE...7------- <br /> . <br /> .__T-f1�--/V`'--1-'� ate`-'-1-- --------- - ------ DATE ..._ ---•-------- ---------- <br /> ------------- <br /> BUILDING PERMIT ISSUED ------------------------- -------------- <br /> . ADDITIONAL COMMENTS -. <br /> -------------------- ----------------------- <br /> -------------------------------------------------------------------------------------------------------------------------- <br /> ------- --------"-------------------------- ------------------------- <br /> ---•------------- ------------------------------------------------------------------------,_------ --- <br /> ----------------------------------------- - <br /> Date --"']�1J 0- - <br /> Final Inspection by: __-•- _ _ - U-�f - t'j ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F <br /> E. H. 9 1-'68 Rev. 5M. ,,, <br />