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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------- <br /> Permit <br /> (Complete in Triplicate) <br /> ------- Date issued <br /> This'Permit Expires 1 Year From Date Issued <br /> ----------- <br /> A <br /> - <br /> Application is hereby made to thd Son Joaquin Local-Health District for a permit-to- constrvct and 'install the work herein <br /> described. This application is nicide in compliance with County ordinance No. 549 and existing Rules and Regulations.. <br /> JOB ADDRESS/LOCATION ------ ------------ -------- ------ .--- -CENSUS TRACT -------< ----------- <br /> -1 - hone ---Vj66__-_?3,ZA7__ <br /> Owner's Name --------------------- <br /> - ------- ---- <br /> ity ------------------------------------ <br /> Address -------------------- ---------- -- <br /> L11 ------------- <br /> Contractor's Name ---------------- -- -70---- -- ------ censi Phone <br /> installation will serve: Residenje-)0M <br /> artment House'E] Commercial iE]Trailer Court E] <br /> Motel [:] Other ---------- -------------------------------- <br /> Number of living Number of bedrooms -ts:-___�- Number of bedrooms - -----1--Garbage Grind --- Lot Size -------------- <br /> ------ --------------------------- El <br /> 1------- Private--------------------- <br /> 1 k -y-Loarn -0 Clay Loam ,0 <br /> Character of soil to a depth of 3:feet: S <br /> Water Supply: Public System and name - <br /> and'E] Silt.0 Clay E] �Pecit-E]—,Sarfd <br /> Hardpan E] Adobe Fill Material ------------ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot-, location of system in relation to wells, bu _s�� <br /> 'ildiri� etc. must be placed on reverse side.) <br /> sewer is available within 200 feet) <br /> NEW INSTALLATION: (No septic'tcin_k;or seepage pit permitted if public <br /> PACKAGE TREATMENT SEPVIC�Tfi�. Kf 1 1 �'Size------------------------------------------------ Liquid Depth -- <br /> , la I i , .tj <br /> -Capacity I - ---------------------- ► <br /> No. Compartments ------ ---------- <br /> -------- Type -------------------- Material <br /> o nearest: Well ------------f -------- 1`6&rid Ut i 66-—---- ------------- Prop. Line ---------------------- <br /> Distonc!e I t Total Length ---------------_------- <br /> e--------------------- <br /> LEACHING LINE . NorbfiLines ------------------ Length Lf,e <br /> 'D' Bok- ------------- Type Filter Material ch Fine-------------------------- <br /> i�_Depth <br /> Filter Material ----------------------------­---------------- <br /> t <br /> ce to nearest: Well—--- ----- ----- Foundation --------------------1- Property Line. --------- -------------- <br /> Distan ------ I * '. <br /> SEEPAGE PIT Depth 7--!-----------I--:- �Dicimeter ---------------- Number --------------------- --- Rock Filled Yes No 0 <br /> t <br /> WaterTable Depth --------------------------- --------------------Rock.Size -------------------------------- <br /> I <br /> Distance to nearest: Well -------- ---- .;------------.FoundationU <br /> ------- ----------- Prop. Line ------------_=------.. <br /> --- - ----------- <br /> REPAIR/ADDITION(Prev. Sanitation t --- Date --------- <br /> a n Permit f-��------------------1-"V ------- ----------------- <br /> ---------------- --------------- -------- <br /> ------- ------ <br /> e -- - ---------------- <br /> -ify Requirern ntsit--------_----------------------- <br /> Septic Tank (Spec <br /> T--------------- <br /> ----------- - ____ -_ . - _4 �_5 <br /> Disposal Field (Specify ReqUir6m�nts) --------- .01 1 1 <br /> I - i --- ---- ---------------------------------------------------- <br /> ----------------- ---- - -------- ------------ - <br /> (Draw stip and required additio-n <br /> --------------------------------- ---- - --------- --- - -,- _r <br /> on reverse side <br /> St. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Ion Joaquin <br /> State LaW511:6cl Rules and Regulations of the Sa'n Joaqui,n Local Health District. Home owner or licen- <br /> sed agents signature certifies the following- <br /> "I certify that in the performance of the work fohich,this"lLshall-not em' <br /> ir,wploy any person in such manner <br /> p .,ermit is issued, I I 'r <br /> - <br /> as to become subject to Workman's Compensation lavirsof California." <br /> NOwner 0Yr <br /> Signed ---- ---------- <br /> Title --------- - ---------------------------------------------- <br /> By ----------- ------------------- --- <br /> (if oth than owner <br /> FOR DEPARTMENT USE ONLY <br /> ...........DATE <br /> DATE ------------------------------------------- <br /> APPLICATION ACCEPTED BY ---- ---- - ----------- - - - <br /> BUILDING PERMIT ISSUED -----------------------------��O_ <br /> 'e.", -1------ - - ----------------------------------------------- <br /> ADDITIONAL COMMENTS ------- --_--------------------- -------- <br /> -- ------------------------------------------------- --------------------- <br /> W7 <br /> ---------------------------- -------------------------- <br /> -4------I_ --,t----F_�--------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------- ---------------- p -4 1 4 <br /> ---------4_4 -----------------I -------- -------- <br /> ----------------------------I----------------- i 11------ --------- <br /> Final Inspection by- ----- ------ Date <br /> SAPa JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b$ Rev. 5M, <br />