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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No ------ <br /> -------------------- 5,z� � - <br />---------- ---------------------------------------------• L I - !I(Cornp�ete in Triplicate) <br /> Application is hereby made to the San Joaq6l61ocal Health District for, a permit to construct and in Date issued-77n/2n-L - <br /> Ttilhi Permit Expires 1 Year From Date issued <br />--------------------- <br /> stall the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Reguldtions: <br /> JOB ADDRESS/LOCATIO -----A0 W ........ -— ------- -------------CENSUS TRACT ------------ ----- <br /> ---------------------Phone --------------------- ----------- <br /> Owner'! <br /> i Name ---�-40/— <br /> -----------1-- City --------------------------- <br /> Xdclr'ess --------- ------=-- nPhone <br /> Contractor's Name ------ - ------------ ------ ----------Lice <br /> 1-�se <br /> ' <br /> Installation will serve: Residence Apartment House-0 Commercial ElTrailer Court i0 <br /> Motel E]Other --------------------------------- --------- <br /> ts Number of bedrooms -----Garbage Grinder/Olp-Lot Size e"0,r---d-P�------------------- <br /> Number of living units:_--- d11� �4 <br /> T'le I --------------------------------------------Private <br /> Water Supply- Public System and name _______-0------------------------------------------------------- N, <br /> Character of soil to a depth of 3 feet: Sand' Silt Clay E] Peat❑EJ Sandy Loom -E] Clay Loom 0 <br /> Fill Material ------------ Iyes'�� ------m------ -F <br /> Adobe pe --------------- <br />• Hardpan E] f <br /> s, etc. mus be placed on reverse side.) �J <br /> (Plot plan, showing size of lot, location of.system in relation to wells, building �1�I <br /> Iewer is available within 2&feet,) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public s " <br /> -7-- 1 <br /> Size-------- - -- - ------ <br /> -- -- -- ----------------- - ----- Liquid epth --------------------------- Z6 <br /> -PACKAGE TREATMENT I I SEPTIC TANK![ I <br /> 0. Compartmen'Is,, ....... <br /> -- - <br /> - <br /> Capacity -------------------- Type Material---------------------- N ----------------------- <br /> Distance to nearest. Well ------------------------------------Foundation -------- ------ Prop. Line ---------- <br /> NI-1 <br /> LEACHING LINE No. of Lines ______-.___ ; <br /> _ <br /> Length of each line---------------------------- Total Length ------------ :��--------- <br /> epth Filter Material ------------------- <br /> `D' Box ------------ Type Filter Material --------------------D ---------------- <br /> ---- ------------------- Property Line. -------------------- <br /> -V Distance to nearest. We ------------------------ Foundation No t3 <br /> yes C3 <br /> Fill�d <br /> SEEPAGE PIT Depth --- ----------------- Diameter ---------------- Number -------------------------- Roc <br /> --------Rock Size ---------------------------- <br /> Water Table Depth ---------------------------- <br /> Foundation -------------------- Prop. Line ---------------------- <br /> Distance to nearest. Well -------------------- Date ----=------------------•----------) <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------------------ <br /> -------------------------------- <br /> Septic Tank (Specify Requirements) __________________ f. <br /> --- - - --- --------------------------Z-71 Ze---------- <br /> Disposal Field (Specify Require <br /> -Or ! ------ ------------------------------- ---------------------- <br /> 1--,r�l- <br /> ---------- ---------------------------------------- <br /> ------ ---- ---- -----------------------------------------------------reverse side) <br /> (Draw existing and required-addition on will be done in I accord.once with San-.Joaquin <br /> -1---hereby---- --certify- -- -----that I----have--------prepared this applicatiori and that the work District. HOMO owner or Iiie1w.— <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health Distri <br /> sed agents signature certifies the following: permit is issued, I shall not employ any person in such manner <br /> "I certify that in the performance of the work for which this p <br /> as to become subject to Workman's Compe sati-an laws of California." <br /> ----------- Owner <br /> Signed - -------------------- ----- ---------------------------- -- -- - --------------- T-/ <br /> By ------------------------:,�--- - -------------------------------- - itle ------ ---------------------- --- ----------- <br /> (If 0 t an. ow;n ; 4 <br /> FOR DEPAtTMENT USE ONLY - <br /> /- - DATE ---- -----��6-::i6q------- ----- ---- <br /> APPLICATION A CEPTE15 BY - -- ------ -- --------------------------------- -------DATE ----------- #,.A .. <br /> -------------- ---------------- -7 1----------------I-------- ------ <br /> I <br /> ---- <br /> BUILDING PERMIT ISSUED,-------- - -- ------ ------------------------------ <br /> b�m-----�-1---------------- ------------------------I-------------------- <br /> ADDITIONAL COMMENTS -------- -- -----/0 ------------ -------- <br /> ----------I---------------------------------------------I------------------------------------------------- <br /> ------ --- ---- ----- ---- I -------------------------------------------------- <br /> -------------------------------------------------------------------- ---------------------------- ----------- <br /> ------/W <br /> ------------------- --------------- 7-n ----------1---------------------------------------------------------------------- <br /> --------------------- - ---- ---- -- - - - -------------------if -- ----- ------------------------------------------------ ------Date - ---------- --- ---- ---------- <br /> Final Inspection by��-w - -------------------------------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 7� <br /> E.H. 9 1-'68-Rev. 5M, 4zi� <br />