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OROFFICEUSE.. APPLICATION. FOR SANITATION PERMIT Permit No. <br /> R 0 <br /> --------- (complete in Triplicate) <br />: __ Date issued <br /> 7 <br /> ------------- ------------------------------------ <br /> -------------------- ------------------ This Permit Expires I year From Date issued <br /> -------------- tall the work herein <br /> --------------- <br /> San Joaquin Local Health District for a permit to construct and install <br /> Application is hereby made to the : ice with County Ordinance 549 and existing Rules and Regulations: <br /> described. This application is made in compliance VA ----------CENSUS.-TRACT -------------------- -- <br /> ---------- --- --- ---7. ------ ------- <br /> TIOR---- ------- <br /> JOB ADDRESS/LOCA 466--- --- -- ----------------I- ------------� -P ne 6--if <br /> ------------- <br /> --------------- <br /> city -- - --------------- ------ <br /> Owner's Name ----- --- -------- F c16,6-?6 _7 <br /> ----I--- -------- ------ Phone ---- ------- <br /> Address ------------------ - --------License # -------------------1 <br /> Contractor's Name -------- ----- --- --- <br /> installation will serve: ResidenceyApartment House-0 Commercial []Trailer Court 0 <br /> k Motel E]other ------------------------------------------- Lot Size ---------laz/L-le--1___>-------------- <br /> nits ---- Number of bedroom ----)1_Garba_9e Grinder ------------ <br /> Number of living u ----------------------------------Private El <br /> ic system and name "-------- PeatSandy Loam .[] ClayLoom <br /> 4la <br /> Water Supply: Pubi Peat 0 <br /> Character of soil to a depth of 3 feet. Sand'[] Silt[] y E] <br /> Fill Material ------------ if yes,type ---------------------------- <br /> Hardpan E] Aclobe'[] <br /> wells,csewergis <br /> etc. must be placed on reverse side.) <br /> location of system in relationo(pl�ot plan, showing size of lot, ubliavailable within 200 feetr)(No septic tank or seepage pit permitted ifp ---------------- <br /> NEW INSTALLATION: I " . 'Size----- ------------------------------ Liquid Depth ----------- <br /> SEPTIC TANK-T Material------------ Compartments ----------------- <br /> L - <br /> PACKAGE TREATMENT I 1 1 --------------- Type -------------------- a,---------------------- No. Line .__.------------------ <br /> Distance <br /> --.----------- ------ <br /> Capacity -Foundation ---------------------- Prop. <br /> Distance to nearest- Well ------------------------- <br /> --------- Total Length __--------- ---------------- <br /> No. of Lines ------------------------ Length of each line---------------------------- <br /> LEACHING LINE —---------- —_--{ Depth Filter Material -------------------------------------------- <br /> 'D'. Box. pe71iier Material ------------- Property Line ------- - -------------- <br /> ------------ Ty <br /> t Foundation ------------- <br /> Distance to nearest: 'Well ------------------------ r---n Yes ❑ No <br /> Diameter ---------------- Number --------------------------- Rock Filled <br /> Depth -------------------- ) 1--------------- <br /> SEEP! <br /> SEEPAGE PIT k .1 •------I.RockSize -------------------------------- <br /> I -------------------- <br /> Water Table Depth ------------- ----------------- <br /> A-FOL 7ndafionlv­7711------- --- Prop. Line ----- <br /> Distance to nearest, Well --------------------- ------------ <br /> Date ------------- <br /> ------- ---------------------------------- -------- ----------------- <br /> RElPAIR/ADDII]ON(Prev. Sanitation Permit#; I f <br /> -- ------------ ------ - -------------- --- - ------ <br /> pecify Requirements) ------- <br /> -----I--------------- - - - --------- - <br /> Septic Tank (S I t I - ---- ---- -- <br /> Disposal Field (Specify Requirements) ---------- -- - 10, , I ------ <br /> Disposal - - ---- -------- ---- A_ - ; --- ------- ------------------------------------- <br /> - --- -------------------------------------------- --------------------------$------ :U q __ - ---- ---------I-------------------! --- <br /> --------------------------------- �side) <br /> ---------------------------- on re�(etrse'; <br /> {Draw existing and required addition % _ � ; IN accordance with Son Joaquin <br /> application and that the-work will be 40-n'Psn- cc %r or licen- <br /> H Health 4 <br /> that I have prepared this a /Sa"n7�oacluin Local ec District. Home own! <br /> I hereby certify t State Laws, and Rules' and Regulations of the <br /> County Ordinances, 1 1 in such manner <br /> sed agents signature certifies the following'. issued, shall not employ any person <br /> this t is issu <br /> figi certify that in the performance of the work for which t is permi i <br /> i i I vj <br /> oMpe <br /> as to become subject to Workman's Compensation laws of Ccl;�w <br /> lifor <br /> \j <br /> -- -- ---- --------- - --- -(N- <br /> ------------10 <br /> wner <br /> ------ --- ----- ----------"- <br /> Signed I Title - - <br /> --- <br /> ------- --- <br /> ----------------------------------------- <br /> BY ------------------ <br /> if of tha o ner) <br /> DEPARY2M NT USE ONLYT'� <br /> bATE --------------- <br /> APPLICATION ACCEPT BY;____---- --- <br /> DAT <br /> ---- ----------- ----------------DATE ------------------------------------------- <br /> -- ----- --- ------------------------------------------------------------ <br /> -- <br /> ---------------------------- --- ------------------------- ----------------- <br /> BUILDING PERMIT ISSUED --- ---------------------- ------------------------------------------------- I --------------------- <br /> ADDITIONAL COMMENTS --------- --- -- ---- - —- -------------------------------------- <br /> ---------------------------------------- ---------- <br /> -----------­��: `,_C:7--------- --- -------------------------- - ---------------- <br /> ---------- - ------ <br /> --------------------- ------ ----- ------ ------------------------ -------------- ------------- <br /> ---------- 1,3 N --------------------- <br /> ------------------------------- ----------- <br /> ------ ----- - ------------------------------------- <br /> Date <br /> Final Inspection by-- ---------- OAQUIN LOCAL HEALTH DISTRICT <br /> P H 9 1-,'68 Rev. SM <br />