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FOR OFFICE USE: APPLICATION .FOR SANITATION PERMIT <br /> I Permit No. <br /> 'plicate r <br /> ----------------------------- ---------------------- (Complete in <br /> -r---------------------------------------- Date Issued ------ ----- <br /> From Date Issued <br /> This Permit Expires I Year <br /> Application ication is hereby made to the San Joaquin Local Health District for ci 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 Regulatiohs.- <br /> ZW.-CENSUS TRACT --- ---- ------- <br /> JOB !ADDRESS/LOCATION --- --------rf.__ I I <br /> ------------------------ -------- <br /> Ownr's Name ----------- ---------------------------------------------------------------------------------Phone <br /> ----------(- -------------- City ------------------ ----- --------------- <br /> ----------------------------- <br /> Contr I actor's Name �;,.- <br /> Instal'lation <br /> ---------------------------=--------License # ---------I--------------- Phone <br /> Effrailer Court 'D <br /> will serve: 4esidence P-Apartment House[] Commercial <br /> Motel7 Other -------------------------------------------- <br /> Numb.trv CM c�a�rb a ,Grinder:* <br /> qfji..ing <br /> ------- ivate El - <br /> Wate� Supply: Public System ai�dn6.Me ------------i:------------------------------------------------------------ -------------- ---------------- Pr, <br /> Character of-soiLto-a-depth.of-3,fe&..-.C-Sctnd!2. Clay Peat 0 Sandy Loam 0 Clay Loam Q <br /> ------------------ -- <br /> Hardpan F-I Aclobb,E] Fil(Material ------------- If yes,type ------ <br /> ie.) <br /> on reverse id <br /> e.]ito wells, buildings, etc, must be placed[Plot plan' iHoWing size of lot, location of system in re N1j <br /> NEW INS* X[AtION: (No septic tank or seepage pit.permitted, if public sewer is available with I62200 feet,] <br /> t epth ------ -------- <br /> 11 Size__� ---------I.........-_z.Liquid D <br /> PACKAGE ftRI-ATMENT I SEPTIC TAN <br /> K'[ ------------------------ <br /> -'No. Compartments ------------­--- <br /> TYPeC�­1-11-- ---��Aateria I <br /> Capacity _1_2_�20---- i'�' <br /> Distance to nearest: Well ----------- -----------Foundati a _/_2---------------- Prop. Line -------- <br /> LEAC LING LINE 4­-`_N' o. of Lines -------;Z--------------- Length of each. line----9rZ--------- ----­ Total Length _/ZZ2 <br /> x !�.!4- ------------------------------ <br /> 'D' Box Type Filter �Depth Filter Material ------ oe <br /> el <br /> 1.'0 ------ Foundation <br /> -------------------- <br /> Distance t nearest: Well --------- Property Line <br /> 2----ile <br /> -0 Ntjmbe�, ------ ---------------- RorkFild Yes No C <br /> E-4* Depth ---------- <br /> ----------------Roc� Size ------ --7 - --------------V <br /> Water Tabte,:aL-pth ------------V---------- <br /> - --------- <br /> Fou <br /> n5datflon ---- Orol$. Line <br /> ----------- <br /> Distance to-hearest-, Well <br /> k/AD ITI (Prev. Sanitation Permit _----------------- ----- Date ------- -------------------- <br /> REPAIR/ADDITION ------ <br /> % <br /> Sept1ic Ta<k!(Specify_ Kuirenents) ---------c<-------------------------------------------- <br /> 1 - <br /> 1 ----- ------------------------------------------- --------------------------- <br /> --------------_------------ <br /> Disposal Fill dj,,,tSpecify Requirements) -------—------- <br /> ---------- <br /> -------------------- i - <br /> -------------------------- ------------------ -------------- <br /> ---------------------- <br /> ---------- <br /> ----------- ---------------- <br /> ---------- ------------------------------------- ---------------------------_--------__-------_------='-------------- <br /> o reQ`e`rse side) <br /> jDraw existing and required additionKi <br /> he-";k will be done in accordance with Son Joaquin <br /> I-her"il,certify that I have prepared this application and that ffiat 'tor :llcen- <br /> d Regulations-df Ae San Joaquin Local Health District. Home owner <br /> County Ordinances, State Laws, and Rules an <br /> sed agents signature certifies the f6ilowing: <br /> "I certify that 1h.the performance of <br /> iis permit is issued, I shall not employ any person in such mariner <br /> as to become sy % pI <br /> /?,ble� ct to Workman's\&-0,0�-n-sthe work for which tta- qws OfXalifornia." <br /> Owner <br /> ---------------- <br /> --- ---- --- ---- ----- <br /> Signed_-V <br /> ----------------------------------------------------------- <br /> --------------------------------- ---- Title ----------- <br /> By -------------------------- -------- -------- <br /> -- -------- ---- <br /> (If o&r_tha\n,'.owne.rk\ <br /> FOR DEPARTMENT_,4SE_0NLY_____-_� <br /> 2 <br /> DATE 1-------- <br /> APPLICATION ACCEPTED BY ....... <br /> - --------DAT--E- <br /> BUILDING PERMIT ISSUED ---------�__n- -- ------------------------------------ - <br /> ADDITIONAL ---------I-------L------------ -------------- <br /> COMMENTS ----------- ------------------------------------- ------------------------------------------ --------------I-------- <br /> I ----------------------- ---------------------------------------------------------- <br /> ---------------------------- -------------------------------------------------------------------- ------------------ <br /> .1, ---------------- --------------------- --- ---- -- ---- --------------- <br /> ------------------------ ------------------------------------------- ------ <br /> ---- ---------------------- ;1 - - -- ---------------- ------------------------------------------ ------------------------------------------------- - <br /> -------------------------------------------------- --------------- <br /> Final Inspection by: ---------------- <br /> ------------------------------------------------­----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev, 5M <br />