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FOR OFF16E 6S'E. <br /> A <br /> APPUCATION FOR SANITATION PERMI <br /> -------------------- ---------- <br /> Permit No- --------------------- <br /> (Complete in Triplicate) <br /> 14 <br /> --------7."------------------- ------------------- - ermit Expires I Year From Date Issued Date Issued -------------------- <br /> �'j <br /> Application is here�ypcide to the Son Jloc(quin,Local Health District for' a permit to construct and install the work herein <br /> described. This application is made in comp Garic'e" with County Ordinance No'. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ­­-------------------------------------------------------------------------------- ------_-----CENSUS iRACT _77?------ ---------- <br /> Owner's Name ------------------------------- -------------------------------------------------------------------------------------------------Phone------------------j--------- <br /> Address --- ----------/�%X_�-----I-------- ------------------------- -----------------------------L-------_. City --------------------------------------------------------- ------------------ <br /> 1 P <br /> Contractor's Name ------------I----------------------------------- -------------------- --------License # ------------------------ Phone ----------- ----------------- <br /> I in sta I I cition.wi I I serve: Residence E] Apartment House-E] Commercial f-ffrailer Court 0M.' <br /> Motel C Other ------------ .4�' �—_i i <br /> -------------------------------- <br /> Numb�er.,�of living units:------------ Oumber of bedrooms ----------- 4 7S�iz e— ------ ----------- <br /> -Garbage Grinder <br /> Water Su�ply: Public System and name ------------- --------- ---------------------- -------- ----------- ----------------- <br /> --------11--------I------- _lPriv'I <br /> Character of so'i to depth of 3 fe'df- Sbnd'C/Si1)'* Clay E] Peat[3/rSabdy Loam E] Clay Loarn 'E] <br /> �11 0 Z,,r I,'y <br /> Q-, ------------- <br /> -,;- ____ I es pe ----- <br /> 4Tdp��n� A El Fill M�teri�<2 �f y ------ <br /> 4-7 i'�4- 1: <br /> doLB <br /> tv -4, <br /> (Plot plan, showing size of lot, iocaMoo �t;system in relat'lon to w0s, �uildings, rtc must be placedl on r!everse side.) <br /> NEW INSTALLATION- �Ib se ptic tanNo-Vepage pit permitte public sewer is a,'vailable within 200 f6ejt,) <br /> PACKAGE TREATMENT, \SEPTIC TANK:[ Size-- ------------------------------- ------- Liquid Dep;lh�---- --------------------- <br /> Capacit\1 �IhA <br /> y ----------- Type --------- Material----------------------I No. Compartm"4�­ ---------_-_ <br /> une ....... <br /> I <br /> Distance Nearest: Well ------------------------------------Founclatig'...-I----------------- Prop, Line --- -------- <br /> LEACHING LINE No. of Lines ------ ----------------- Lggth of each line------- ------ ------ ---- Total Length J ---_---------- <br /> 'D' Box ------------ Type Filte/material --------------------Depth6 Filter Material -------------- <br /> 1 -1- -----I----------------- <br /> Distance to nearest. Wefl--------------------------- Foundation ---------- Property Line ------------------------ <br /> SEIi�WQ; PIT I Depth -------------------- Diameter _�------- ,ej;_Number --------------- Rock Filled I, es E] No .0 <br /> Water Table Depth --------------- ---1_7===Rock-Size-t!,rn3------------------------- <br /> Distance to nearest: Well ------------hL-------------------------Foundation ---------- --------- Prop. .1nef---- --------------_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------1 1- --------------------- Date ---------- ----------------------- <br /> N, <br /> SepticTank JSpecify ReqUirements) --------------------------------------------------------------------------------------------------------------- - --------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------- -11--------- <br /> _�11 I ­--------------- <br /> --------------- ------------------ --------------------------1!�----------------------------------------------------------------------------------------------------------- ----------------- <br /> ------------------------- ---------- ---------------- --------- ------------------------------------------------------------------------------------------------ <br /> ----------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this applicatRon and that the work will be done in accorclan- ith Scin Joaquii- <br /> ' 'i ce 'Aff <br /> County Ordinances, State Laws, and'Rul ocidit/lAealth District. HoL own6 or licen- <br /> es an ,Regulations of the San Joaquin L <br /> sed agents signature certifies the followinIN <br /> g: <br /> "I certify that in the performance of the work'for whicgthis"�p�rmit is issuedt,7110 h lot'employ any person in sich manner <br /> as to become subject to Workman's Compensation�Nows of Ca1yfforn-ila," *S <br /> Signed ---------- ---------------------- <br /> By ----------------------- ----- <br /> ---- ---- ----------------------------------------------------40.wner <br /> ----------------------------------- --------------------------------- Title ---------- ----- ----------------------- ---- <br /> (If other than owner) -�) `-, <br /> FOR DEPARTMENT IJSO�IONLY <br /> APPLICATION ACCEPTED BY -------------------------------- ------------------------------------- -- --------- D-AIT E ---- ------------------ ----------------- <br /> BUILDING PERMIT ISSUED "%%, <br /> ----------------------------------- ------------DATE------------ ------ <br /> ADDITIONAL COMMENTS -- ---- [ <br /> ------------------------------------------------------------------------------------------------------------------------------------------- -------------------- -----------I----------------- <br /> ---------------------------------------------------------------------------------------------------------------- ----------------------------- ----------------------7111"�d----------------- <br /> ---------------------Z-------------------------------:-------------------------------------------------------------------------I------------------------%11 --------------- ------ -- - -----I------ <br /> ---- Dat__� <br /> Final Inspection by: ---------------------r------------------------------------------------------ ---------------------------------- e <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />