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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT <br /> 1 ._34..._.__ <br /> Permit No. ...7.`?l•-•�• <br /> .......................... (Complete In Triplicate) _ <br /> s <br /> ...........1.111-1 Dote Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local <br /> with edlth Cou District <br /> ordinance permit <br /> and existing Rulesand talndhRegulationsrei�+ � <br /> described. This application is made in compliance <br /> A / / CENSUS TRACT ......................... <br /> J013ADDRESS/LOCA?#ON i� ✓�'�L1�.�4u `'`! ....... <br /> i <br /> :1111..... .....Phone .............1111.:. <br /> Owner's Name <br /> ...... .1fC111� <br /> �-..._...-. .................................1.11...1...........City — <br /> Address <br /> # .yJ Phone'e .. . <br /> 4W...Q <br /> .....License ... <br /> ...1.1_.1.1 <br /> t <br /> Contractor's Name ...... <br /> Installation will serve: ResidenceApartment House Commercial[]Trailer Court 0 - S <br /> Motel ❑Other <br /> ..---1111----11 .............. r <br /> Garbage Grinder .:.......... Lot Size <br /> Number of living units:_.. Number of bedrooms -. ••-- 9 <br /> .................. ; <br /> 1111 <br /> Water Supply; Public System and name ........................•••-•••• Private <br /> ---•--•----1111.................Cia .._ <br /> PP Y= Clay Loam ❑ <br /> Peat❑ Sandy Loam C3 Y <br /> Character of soil to a depth of 3 feet: Sand'Q Silt❑ Y ❑ ' <br /> Hardpan[] Adobeo Fill Material ............ If yes,type ............... ............ <br /> ' lot location of system in relation to wells, buildings, etc. must be placed on reverse side.)' <br /> {Plot plan, showing size of , <br /> NEW INSTALLATION: (No septicstonk or seepage pit permitted if public sewer is available within 200 feet,[ <br /> I SEPTIC TANK ] Size.. -X••�� <br /> ----_. Liquid Depth ...... "....._...... <br /> PACKAGE TREATMENT [ ] "' <br /> i r Capacity fT-c17----- Type • <br /> E.e;l5 . Material...�A,��.�No. Compartments ......� . <br /> ` Foundation .../42............ Prop. Line �? .......... Z4 <br /> 1.111. <br /> Distance.to nearest: Well ---.��.•....0.......... ,_ <br /> LEACHING LINE [ ] <br /> No. of Lines ----�--... Length of each -7, 7S.. Total Length ..�70............... <br /> r <br /> ? ......Depth Qe <br /> th Filter Material ....../4?........................... <br /> © Box Type Filter Material <br /> Property Line ... .... .........•' <br /> Distance to nearest; Well ... .--..1111 Foundation _.. p rtY <br /> SEEPAGE PIT [ { Depth ._�41 � <br /> .----_-_-. Diameter 2-.�---. Number <br /> ............. Rock Filled Yes &-40 �❑ <br /> I _.......Rock Size _. .!,�-�C.l� •- . <br /> ell <br /> Water Table Depth <br /> ® Foundation ­/ .......... Prop. Line ........... 1111..._ <br /> . Distance to nearest: Wel! ..._.�'�f1111..----------------......... <br /> . Date <br /> I REPAIR/ADDITION(Prev. Sanitation Permit# " <br /> -----••- <br /> ----------------- -------------------- .......... <br /> Septic Tank (Specify Requirements)................................................. <br /> , <br /> Disposal Field (Specify Requirements) .---------_...... .............. ............................ <br /> -------------------•--------------------- <br /> {Draw existing and required addition on reverseside) <br /> 1 hereby certify That I have prepared this application and that the work will be done in accordance with San .loagvin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health.Distdct. Home owner or licen• <br /> sed agents signature certifies the following: p arson in such manner <br /> "I certify that in the performance of the work for'which this ermit is issued, I shall not employ any p <br /> F as to beco ublect ta, orkman's C mpensation laws of California." <br /> Signed ---- L` -----------•- Owner n <br /> ----------- <br /> sY -------------------------------- - -------- 1111 <br /> _• <br /> Title -- ......" �------------------- <br /> if other than owner) <br /> R DEPARTMENT USE ONLY <br /> . - ��`�=�7---111.1... <br /> APPLICATION ACCEPTED B =---- ------- DATE <br /> i ,BUILDING PERMIT ISSUED _..__:`.r........................•-------,11.........11_ <br /> ------•-------- ---------••----1111-.,__.._:.._..DATE - --•--1111------•-•---- - •---•---•• -- <br /> ADDITIONAL COMMENTS .. -----••-------•-••--• ................•----•...._.. ..---....._...._._.__....-. <br /> Y _.. .. ;. .... -----.1111-......_.. •----....--•------------------_... ...._._.. . --•-•- f.� ............................r� - -.. . <br /> 1.11.1 <br /> Date -- <br /> final Inspection b �=•----•------•--•---• ...................................................----• <br /> p by.. <br /> 13 24 1-68 Rev. 5H j SAN JOAQUIN LOCAL HEALTH € ISTRICT ��7� 3 <br />