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FOR OFFICIO USE:
<br /> APPLICATION FOR SANITATION PERMIT
<br /> (Complete In 'triplicate) Permit No. .....................
<br />............................._,.............._.......... This Permit Expires 1 Year From Date Issued
<br /> Data Issued A..............
<br /> Application is hereby made to the San Joaquin Local Health District for a 'permit to'Construct and install the work herein
<br /> described. This application is made in'tornpiionce with Couniy Ordinance No. 549 and existing Rules and Regulations.
<br /> JOB ADDRESS LOCATI .............CENSUS TRACT
<br /> Owne s Name.,...-. 1 . " -t%�.7. .. _.. . ._ . .. ..,....... .:...... ..'•.Phone5...../.. .
<br /> Address ..•...................{I1.Q :.�-L. . .. City :........:...
<br /> _ _
<br /> Contractor's Name : .'e ' r':. C2 f'I{ {:License ,#.�- ��7.�i j. ph tie .` b�.¢
<br /> k� {til +
<br /> Installation will serve: Residence-[ Apartment'House fl-ComMercial ❑Troller Court .
<br /> Motel:0 Other,.. • � j I
<br /> g .N rbag Grindier L' Size -...� f S
<br /> Number of living units.... .• ...............
<br /> umber of bedrooms.,. Ga
<br /> Water Supply: Public System and name __...-- ..........1. �. ..,...... u-....."..^-t. ..... Private ❑
<br /> Character of soil to a depth of 3 feet: Sand❑ Silt[3: Clay ❑ Peat❑ Sandy Loam l 'Clay Loam ❑
<br /> } Hardpan Adobe Fill Material ... ...... . If yes.#type ---- -- ----
<br /> (Piot pion sho"Wing site oi, lot, location.,of system in...relottort to wei[s, ..build,ings,,.etc.•,inusf..be; placed-.on itevetse ,fide.),
<br /> a
<br /> f:
<br /> NEW INSTALLATION: INq septic tank or sieepd9 a h it°#?erm1�ltted: if i61,t sewer is available with'irt 200 feet,]
<br /> IC TANK , Size _ _ .. :Liquid Depth .... ....................
<br /> PACKAGE YREATMENT [ � SEPT � �'[ � � � _ _
<br /> : Capacity --- ------ Type .......... Material........... iNo. Compartments ------ .......
<br /> Distance td nearest We li '.. :.Foundation ............. Prop. Line i...... _.......
<br /> LEACHING'LINP :SN0: of"Cines ...:..... ...... ..... Length?of peachline._._�....... ... . . Total `Length ..._. .__...__.y
<br /> ° f s
<br /> ,I'D Boz Type filter Material'.._. "Depth Filter M6terial
<br /> } Distance to neatest:;Well .._7-:__:- C > foundation :: Property Line
<br /> SEEPAGE PIT E 1 : Depth Digmeter• -y . .Number .... _::: ,......... -Roth Filled .:Yes ❑ .No i❑l r
<br /> Water .Tablo .Qepth �, Rock Sizel~ .. I,
<br /> Distance to n: eor�st: Wel( .. . t 'Foundation . Prop. Line ...... .
<br /> REPAIR/ADDITIDN(Prev. Sonitaiion'Permit .... Date ........................ ...
<br /> Septic Tank (Specify Requirements) ...;..... ;_...- ...,...._
<br /> jj -
<br /> Disposal Field (Specify Requirements) ....-: ...
<br /> ............� __. "..._..:._-•-- .....
<br /> �•
<br /> .......
<br /> . ,. __._,..........._.._... :....... ... ...
<br /> i (Draw existing and,required addition on reverse,side)
<br /> hereby Qrd certify art as State
<br /> fe tprepared this applitafion and that the ;work will+Ise done in accordance with San Joaquin
<br /> Coun
<br /> >ry' aws; wird Rules- dhd Ragiilatifins Pf the Sari 7oaqu+n'"Loia1 Health Distr�et I�bm�'itVVner evlith-; l
<br /> sed agents signature certifles..the f;116wiri"I tertity that in the perform6ricia �:.
<br /> as t become sub ect #o Wofkritan sfiComperi lan oiws ofi it I$:
<br /> issued, 1 shbil no! ploy any pir:oit in :uch marnnrr
<br /> :
<br /> i
<br /> :.......:........,..
<br /> Signed . -�- -- flyvneF .... , 1
<br /> BY :...._ ::.. it�e
<br /> (If other an owner) '
<br /> .....:.. ...
<br /> FOR DEPARTMI~NT SE ONLY 1
<br /> 3
<br /> APPLICATION ACCEPT D BYz
<br /> BUILDING PERMIT ISS ED :..a J' ...... _DATI .: , .. {.
<br /> ADDITIONAL COMMENTS ... ... .. .......` ... r. _: :,:.::
<br /> ..... ... ..
<br /> ;: :;. ....................... ............ --- ............. -- ... ... .. ... ...._;
<br /> j - ... ... .. ... ... ... .. ... ... ....
<br /> final inspection b Date
<br /> f `SAN JOAQUIN :LOCAL HEALTH 'DISTRICT 7A�
<br /> i ''�i-' -�..._�...,-..«...-...,a.a.,.-..-.r....,•....w...,.....r..o.....�....w�f - -_�.•...-...wsw.rtv...v.,,.. -� - .. ..d.., .»Lw.-wn1���..,,A-.o.�.J.-y.., .-..i....,.,...s'.,.�...,.:...,.,a...
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<br />;i;Ak.A_3 24 1-'68 Rev. 5M --- -- — 7/7231 .
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