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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------- ------------ ------ Permit <br /> (Complete in Triplicate) <br /> Date Issued <br /> ---------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Son 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 /> JOB ADDRESS/LOCATION! Z ------ --- ----- ----CENSUS .TRACT -------4-----"-------- <br /> , / <br /> Ii-v'r-N <br /> 1�; Phone -----7_,?_2-_-_0327 <br /> ------ -------- --- <br /> Owner's Name - A-------- --- --- -- -- -- -------------------------------------- <br /> ---------- --- ----------7- <br /> A ---------- y --------XV - -----------------------_---- <br /> Address ------z----------------1V I I C t <br /> ------ A, __ Pone __V6Z &Zl-7 <br /> Contractor's Name -ICT-2-1-0------------:License ---------77 <br /> Residence idenc.e E]Apartment JHouse-E] Commercial �[]Trdiler Court <br /> Installation will serve: I <br /> M-6tel [-]Other ------ --------- ----------- <br /> Number of living units:----- ---- Number of bedrooms ---'5--.-,Garbc!ge Grinder391---------ILot Size -------1___1q1r_1qA-—------------- <br /> Water Supply: Public System and name ------`--------------=-------`• ----------- --------------- Private E] <br /> ------ ------------- ------ -------- <br /> Character of soil to a depth of 3 feet; Sand -Silt0 F y 0 Pelt CN,6.m CIO -'sSancly b <br /> Hardpan);J'_ Adobe E] Fill Material.-_h:'�_lf Yese,.,V­pe ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells,, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION. <br /> (No sept)c`tqp' or seepage pit permitted if public sewer is av6iId6WZ7itKi`n­200 feetJ <br /> PACKAGE;'TREATMENT SEPT TAK I I Size--- -yLiqulcl Depth ----------------------- <br /> -------------------------- <br /> "t <br /> ----- -- < -T— No. Comp rtments ------ ............. <br /> Capacity _. _��)_-, Type ------------ ------- Materidl--------------------- a I <br /> Distance to nearest. Well ---------------------- +-----___FoundationLine .--_----------------- <br /> LEACHING LINENo.1 of Lines Length of each.%ne._/--- ------------------ Total Length- -----------•.._._...--•------ <br /> D' <br /> --------- ................D' Box --- -------- TY01 Filter Material --------------------I'Depth Filter Material ---------------------------------------- <br /> ----- <br /> Distance tbJn\\ea"rbst- ell ------------------------ Foundation ------------------------ Property Line ------------------------- <br /> SEEPAGE PIT Depth --------------�_\----- rDiameter ---------------- Nu er --- ❑I_- ------------------- Rock Filled Yes 'E] No 0 <br /> I lo _Rol Size --------- <br /> WaterTable Depth -,----------------------------------------- --- --------------------- <br /> Distance to nearest: Well --------------------_-------------_,.__.Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/A lPN(Prev. Sanitation Permit --------- ---------­---------------- Date ------------1---------------------j <br /> SepticTank (Spbcify Requirements) -------- -------------------------------------------7---------------------------------------------------------------------------------- <br /> Disposal Field (Specify RequireVme s) .--- -----7�_ ------------------ ---------:,;------------------------ <br /> ---- --------- <br /> - -- - - -------------------- <br /> ---------------- ------ -------- ---- ----------- <br /> ----- ---- ------- ---------------------------------------- <br /> ------ -------------------------- ---------------- ------------------------------------------- <br /> (D.r.a,w existing'and required addition on!re�verse side) <br /> I hereby certify thatI lavprepared this application and that the work will be done in accordance with San Joaquin <br /> SLaws, <br /> County Ordinances, tate A. and fll�ules and Regulations of the San Joaquin Local;Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> f <br /> "I certify that in the performance of the work or whi ich.this-permit-is-issued,-I-sholl-not employ any person in such manner <br /> as to become subject to Workman'i Compensation laves of California." <br /> Signed ------------------------------- Owner <br /> -- -- --- ------------ -- <br /> --------------------------------- -Title ..... <br /> By ------ - -------------- <br /> ( othe <br /> ----(tnr,othe n owner) <br /> F109 DEPARTMENTS SIE ONLY_..o.-,,.,.-. <br /> APPLICATION ACCEPTED BY _-TA_R-_0---------:------------------------------- - X--------------- ------ DATE ----- <br /> ­BU--I-L-DI-N---G-- PERMIT--ISSUED <br /> --------------------------------------------------------------- <br /> --------------- ---- ---- - ----------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------D-------A--------T------E------------------------------ <br /> -----­-----­--------­---------­------------------------------------------------------------------------------------------- <br /> ADDITIONAL COMMENT --- ---- --------------------- <br /> ---------------------------- -- ---- - --------- <br /> -- --- -- - ----------------------------------------------------------- <br /> --- - ------ Z - <br /> ------ <br /> ---- <br /> ------- <br /> - <br /> - <br /> - <br /> Final Inspe Date ---------- - ------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />