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OR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> V - ------------- <br /> Permit No <br /> (complete in Triplicate) <br /> Date Issued <br /> ------------------- ----- ------- ]_ _ - <br /> I ,e . This Permit Expires I Year From Date Issued <br /> --------------- <br /> ------------- work herein <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the <br /> described, This application is made in compliance with County Ordin nce No. 549 and existing Rules and Regulations: <br /> -------------------------- <br /> ----------CENSUS TRACT <br /> JOB ADDRESS/LOCATION Phone ------------------------------------ <br /> owner's Name ----------- <br /> ZI A., . .. ............ <br /> ----------------------- <br /> --------- City <br /> 4owAddress ---------------------------------------------------------- e. Phone <br /> �_ V�_ Zof—-------------------------------License #1,doaf- <br /> Contractor's Name --- 0_4F ercial �E]Trailer Court :E] <br /> Installation will serve. ResidenceXApartment House�E] Comm <br /> motel []Other -------------------------------------------- <br /> Lot Size _44 <br /> r-1-109-------------------- <br /> r <br /> Number of living units-.---/---- Number of bedrooms,--,?------Garbc�ge Grinde <br /> Water Supply: Public System and name -----------------------------------__------------------------------------------------------------I------- ---.Private% <br /> clay F1 Peat El - Sandy Locimf:] Clay,Loom [I <br /> Character of soil to a depth of 3 feet: Sand'El Silt 0 <br /> Hardpan Adobe $ F ill Material ------------ If yes,.type ---------------------------- <br /> relation to wells, buildings, etc. must be placed on reverse side.) <br /> (plot plan, showing size of lot, location of system in ilable within 200 feetJ <br /> rmitted if public sewer is ava / <br /> NEW INSTALLATION: (No septic tank or seepage pit pe de ----- --- <br /> EPTIC TANK Size ---- ------- Liquid Depth,4�� <br /> PACKAGE TREATMENT I I S1 <br /> No. Compartments <br /> Ca pacify/A�Ap---- Type�ody <br /> Material- <br /> ell -------- - - -----------._-Foundation - --------- Prop. Line <br /> Distance to nearest: W ine__�?10. ---- ------ Total Length -------- <br /> LEACHING LINE No. of Lines __Aj----------------- Length of each I <br /> ------------ ----------- <br /> 'D' Bo Type Filter Materia pigeepth Filter Materia <br /> -------- Property Line ---------- <br /> x <br /> 4K ation <br /> Distanc 'to nearest Well ------/>V---I-------- Found <br /> 9------ Number -—-------------- Rock Filled YesX No..0 <br /> SEEPAGE PIT Depth ------ Diameter J 4. 0/,W AV <br /> Water Table Depth ------ ---------------------------Rock Size /i�_-IT!- T--------------- <br /> i ' / -- ---- Prop. Line <br /> e to nearest: Well ------- --------------------Foundation <br /> Distanc <br /> tion Permit# -------------------------------------------- Date ---------------------------- <br /> REPAIR/ADDITION(Prev. Sanito ------------------ <br /> �I -------------------- -----------------I—-------- <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------- <br /> Disposal Field (Specify Req I uirements) ----------------------*-.1---------------------------------------------------------------------------------------------- <br /> �I ------------ ------------------------------------------------------------------------------------­- <br /> ------------------------------ ------------------------------------------ ---------------------------- <br /> ---------------------------------------L------ --------------- ------------i-d-e-)----------------------------------------------------------- <br /> --- -------------------------------------------------------- <br /> (Draw existing and required addition on reverse s done in accordance with San Joaquin <br /> epared this application and that the work,will be n ner or licen;;- <br /> I hereby certify that I have pr <br /> 'Is, and Rules and Regulations of the San Joaquin LocaV Health District. Nor a ow <br /> County'Ordinances, State Low <br /> sed agents signature certifies the following. <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 become subject to Workman's Compensatiovaws of California." <br /> Owner <br /> i'le <br /> Signed ----------------- -------- ---- --- ------------- ----------------- -- T <br /> Title ---- - -------- ---------------------------- <br /> By ------------------------------- --- -- <br /> (if other owner) <br /> FOR DEPARTMENT USE ONLY <br /> ---------------------------------- .... ----------- <br /> DATE <br /> . . . . ...... ............... <br /> 4e— -- --------- -- <br /> APPLICATION AC EPTED BY -------- --- -----------------------------------DATE ------------- ------------------------ <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------- ---------------------------------------- <br /> 'I ---------------------------- ------ ------------------------------------------------- <br /> ADDITIONAL COMMENTS --------------------------- -------------------- <br /> I ----------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------- ------------------------------------------------------------ <br /> ------------------- I ---------------------------------------------------------- <br /> ----------------------------------- ------------------------------------- ----------------------------;;-------- ----- ------------I------- <br /> --------------------------- - ------ --------------------------------------------------- --- ----------------- <br /> Date <br /> il Inspection by- -------------- - -- ---- -- ---------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1-'68 Rev. 5M <br />