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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------- -------- ------- <br /> ------ ---------- (Complete in Triplicate) Permit No. <br /> d I <br /> Date Issued----------------------------------------- -- ------------ This Permit Expires I Year From Date Issued Da7d <br /> Application is hereby made to the San Joaquin <br /> Local Healthbistrict for a permit to construct and install the work herein' <br /> -- <br /> described, This application is made in compliance with County Ordinance No. 549 and existing Rufe's eana' Regulations: <br /> 143f%/hO <br /> JOB ADDRESS/L2 -- <br /> A.-/---- -------------CENSUS fRAC,T <br /> -- --------- <br /> ------------- <br /> Owner's Name <br /> e,;44AN---- ------------------------------ -------------Phone.- <br /> ----------COY004ovd - <br /> -Vt V <br /> Ar <br /> Address alo-�x-4 _1006e&C--------vm---------!--. city _5 ------- ---------------------------- <br /> Contractor's Name Nftowl _' <br /> 0 --------------------------------License ------ Phonle#�//�7_19 ► <br /> Installation will serve. Residence IM Apartment House,E] Commercial Trailer Court <br /> Motel El Other <br /> ' 61 1 <br /> W1 'a <br /> Number of living units Number of bedrooms _mt-----Garbage Grinder Lot Size - -- ------V__/41a <br /> Lj __e - --------- A <br /> _,.4 r <br /> Water Supply: Public System and name -----------------------------0-------------------Private E] <br /> Character of soil to a depth of 3 feet: Scmd'E] Silt 0 Clayvn IL Peat E] Sandy Lod.rh -E] Clay Loam Yj <br /> Hardpan ❑E] I .1� - <br /> Adobe Fill"Mdferial ------------ if <br /> IL V,0�.e W,type <br /> [anowing <br /> (Plot P , s size of lot, location of system in relation to eIls, buildings!Vvetc. must be placed on reverse side.). <br /> NEW I LIL ' I N.A(No septic tank or seepage pit permitted if pub I!c14sde1weF0,is available within 200 feet,) <br /> 1K 9 *."N <br /> PACKAGE TREATMENT*4 j SEPTIC TANK f Size Size- IL- - ------------------ Liquid Depth __��4V!!_.----- <br /> I — IL- <br /> Capacity-- Type -ReCol-06-0- Miaterial_ No. Compartments ------A----- <br /> Distance to nearest- Well -------/Vd--------07----------Foundation ----4/0------------- Prop. Line ---------- <br /> LEACHING LINE N6. of Lines <br /> ----------------- Length of each hne_____/00__* ---- Total Length ------ ........ <br /> 'D' Box ---- ------- Type Filter Material Ra_a, -------Depth Filter Material ----/9----------------­- ----------- <br /> 'r*ProI56ftSP Line _4 -------_----- <br /> Distance to nearest: Well !-�!A/A-------- Founda651n <br /> J <br /> - ------ �ter --- Number -------------------- Rock Filled Yes No <br /> SEEPAGE PIT Depth Diame <br /> Water TableDepth ------- -----------------------------Rock Size _-//A <br /> tasta'nce to nearest- Well --------------------------Foundation Id------------ Prop. Line ------­----- <br /> ' " '. .I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------ --------------------------------------Date <br /> _W)Wepo-.--I.........I----------- ---------- ------- ----------- _ <br /> --------- <br /> Septic Tank (Specify Requirements 1i <br /> Disposal Field (Specify Requirements) ----------------------------------------------------------------------------------110 <br /> ----------- ----------------------------------------------! I ---- ---------------------------------------------------------- <br /> - -----------------------------------Pie -------- ----------------- ---------- <br /> ------------------------ --- ------------------------------ ---------------------------------------------- ------------------------------------------------------------- <br /> ----------------------------------- <br /> (1 raw existing and required addition on reverse side) <br /> .�lthis,application-vand-4that-ithe,workywilimbevdoneNin-ra <br /> I hereby certify that I have prepare I <br /> ccordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the follo'wing: I <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to b ame subject to Workman's CorrIpensation laws of California." <br /> Signed -- ---- ---- <br /> -r <br /> - Owner <br /> By <br /> ------- - ------- -- - ------------------- Title <br /> (if other than owner) <br /> ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ - <br /> ----------------------------------------------------- -DATE <br />-- -BUfLDING-PERMIT-ISSUED%__ _ <br /> ---------- ------- ------------------------DATE.-- <br /> ADDITIONAL CO ------------------ <br /> -------- --1� ---- - -- -- ------------------------------------------------ ------------------- ------- ---------------- -------------- <br /> 'O_ �'T ---- --- ---- ----- --------- ---- <br /> rz7&-�-- — - --------------------------------------------------- X-------------------------------------------------------- <br /> ------------4.......0�x - <br /> , 11 --=-I-7� V:Y_ -------- -- - ---------------------------------------------------- ---------------------:77=:----------------------------------- <br /> --- ----------- ------ - --- --------- .: <br /> Final Inspection by: ------ W—V ------------------------------ <br /> --------------- ------------------ <br /> ------------------------------------------------------------Date <br /> - i4 JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />