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FOR O.FFICE-US E:." <br /> ------- APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------- (Complete in Triplicate) Permit No. T-L-k-5 <br /> ---------------------------------------------- <br /> This —Date-Issued.,: <br /> Permit Expires ] Year From ssuid <br />—--------------------------------------------------------- Date I <br /> Application is hereby made to the So� JoictqZin4ocal,Health Q;1s`trit",foaAjp-eFmi--- <br /> r st7'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 ---- -- <br /> .......5-------- ------KI-All- CENSUS,,TRACT <br /> Owner's Name ----- - --- -----% <br /> C-q----------------------------------------- <br /> - -------------I-------------------Phone <br /> Address <br /> .License # 965�__t 7- Phone _4�',32_f_WYAP <br /> 11 A I r <br /> --------- City ----------------------------------------- <br /> Contractor's Name <br /> Installation will serve.. Residence `Apartment House 0 Commercial,:[]Tialler Court <br /> Motel [] Other ------------ <br /> Number of living units:---- ---- Number of bedrooms __3-----Garbage Grinder 1,414"ot- Lot Size ---- -f—--------- <br /> Water Supply. Public System and name -------------------------------.-------------------------------------------------------------------------------i Private <br /> Character of soil to a depth of 3 feet: Sand`f91Q Silto Clay E] Peat E] Sandy Loam 'El Clay Loom ❑ <br /> a la <br /> Hardpan E] Adobe E] Fill Material ------ ----- If yes,type ------------ <br /> (Plot plan, showing size of lot, locatio"'n" of system insrelation to wells','&'ilcling�s',"efc. must be placed on reverse side.) <br /> I <br /> NEW INSTALLATION:' (No <br /> I(No septic tank or seepa peemitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK't>Cvl- Size------XX Or/ <br /> le-k-15--—------------- Liquid Depth ------------- <br /> Capacity _ o_ ±___-------- Type <br /> ' <br /> No. Compartments <br /> f) <br /> stance to nearest- Well ------6--o Foundation __14----------- --- <br /> --- Prop.-Line I---------------_- <br /> LEACHING LINE <br /> No. of Lines ---3 --- -- --------- Length of each line__-4T_(0--------------- Total Length __;Z_yb-------------- <br /> D' Box,)4Z&.. Type Filter Material IFIO-1 ________Depth Filter Material ----hp------ -----------_------------- <br /> Distance to nearest.'Well --------- Foundation --9---------------- Property Line i —-------------- <br /> 1 I ------ <br /> SEEPAGE PIT Depth ---------------------�'Diameter ---------------- Number----------------------____-- Rock Filled Yes C] ❑No 0 <br /> Water Table Depth,=-----------------------------------------------RockSize -------------------------------- <br /> IL Distance to nearest: Well -----------------------------------_____Foundation--___,,,,________--- Prop. Lii)e ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------_17��wl:Z)__ <br /> Septic Tank (Specify Requirements) -------------------I------------ -------------------------------------------------------------------------------- <br /> Disposal Field (Spec-4y-Requ4remenW ....... <br /> ----------------------------------- ---------------------------1--ri�--------------------------------- <br /> ------------------------------------------------------------------------------------------ <br /> ------------ ---------------------- - <br /> -1------------------------- <br /> -------- <br /> ---1_�-------------------------- ---------------------------------------------------------------- -- <br /> (Draw existing and required-addition--o-n--reverse side) -- • <br /> I hereby certify that I have prepared this application and that the.work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in th.e,p4rformance of the vV6kk.for which this permit is issued, I shall not employ any person in such manner <br /> as to become subleii to Workman's Compen4siiition laws of Calif <br /> Signed ------- <br /> - -- ------------------------------------------ -Owner <br /> By <br /> ----------------- Title --------- ----------- <br /> /0A.' ___ <br /> (If other-than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----1--i-- ----------------------------------- ------------------------------------ DATE <br /> BUILDING PERMIT IS I UED ----------------------------;-------------------------------------- ------------------------------------DATE <br /> ADDITIONAL COMMS ------- -- --------- <br /> ------ ------------ --- --- ------------------------------------------------------------------------------------ <br /> - ---- --------------- -- -------- - ----- - -- - -- - -- ------------------------------------------------------------------------ <br /> -------------------------------------- ---------- ----- ---------- ------- ------- -- ------------------------------------------------------------------------ <br /> --------------- ------------------------ ---- ------------ <br /> Final Inspec ------ ----- -------- -- --- ------------------------------------- <br /> 3e ---------------------Date <br /> ----------------------------------- --- ---- ------ ------------ij-------- <br /> -7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />