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- ---------- <br /> FOR OFFICE.USE: <br /> r Cyt APPLICATIOL4 FOR SANITATION PERMIT <br /> r- <br /> (Complate in Triplicate) Permit No4 _75� 517 <br /> -------;-------------- <br /> -- --------------- ----------------* <br /> I---------------- This Permit Expires I Year From Date issued Date Issued <br /> Application is hereby rrjode to the Son Joaquin Local Health District for a PGrMIt to Construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations:, <br /> J." . <br /> JOB ADDRESS/LOCATION <br /> ¢/L.. -- _ . ....... ...CENSUS TRACT .... ................ <br /> Owner's Name --- tla_4. - <br /> .................. ...e----- Phone .................... <br /> Address ...... <br /> . ......... ......................................... <br /> Contractor's Name ......... A2 7- --------_-- <br /> License # ------------------------- Phone <br /> Installation will serve: Residence 0 Apartment House�] Commercial iDk Iler Court 0 <br /> T19 <br /> Motel E]OtherXae-..r <br /> - ----------------------_ <br /> Number of living units:..... ----- Number of bedrooms _-'2 ...Garbage Grinder --- --- Lot Size --------- <br /> f . I I - ---- ...... .................... <br /> Water Supply-.-Public System and name ...?-----­----------------------*------------­-------------- ----------- ------- ­_ -----------------Private <br /> Character of soil to a depth of 3 feet: Sand 0 Slit 171 Clay E] Peat[] Sand Loam'm &'-Clay Loam 0 <br /> HardpnEAdobe,E]- Fill Material ...........if yes,type----------- ..... ...... <br /> (Plot,'plan, sl�o�ing size_ofj.0tj*CatI*n .of.iystem in relation to wells, buildings,' etc. must J on reverse side.) <br /> I <br /> NEWINSTALLATION: i (No septic tank orse pit permitted if public sewer is available within 200 feet,)PACKAGE TR.EATMENT [ ] SEPTIC TANK[7 Size.- ------------------------------- ....... Liquid Depth ............_­­...... <br /> TypeAt".- Z.... Material No. Compartments ......... <br /> Distance to nearest: Well ---,549..........................Foundation ...................... Prop. line ............... <br /> LEACHING LINE of Lines ---A- -------- .... Length of each line-- Total Length _.16o_� <br /> V Bo 0 Type Filter Material*-4�_&Ae.Depth Filter Material ............ <br /> Distance to nrrest! Well ... ..... Foundation ------------_--- ... Property Line ........ <br /> Depth <br /> e ock s <br /> Water aPt <br /> e - ............. <br /> �,_'%)Istance to n st: F dot* ------_----_ Prop. Line ..................... <br /> REPAIR/ADDITION(P. Sanitation Permit# ----..-•-----------...--- <br /> IS ------------- ------------- Date -------------------- ....... <br /> Septic Tank eclf�'Requirements) -- <br /> . .......... ...­_ __11........................­_­...... ............ .................. <br /> Djsposal Field, IS edfy Requ'irements) ...................................... <br /> ......y i <br /> .............. .....................­............... . ......... <br /> -- ----- ------------ -.. ......... ......................... A <br /> ................. ....... .............. ------ ..................... ­............... <br /> ............... <br /> -- --- -------- ..... -- ------------------------- ----------- ---------- ........._........ .............. ................ ......... <br /> (Draw existing and required addition on revmMsi <br /> 'It be done in accordance with San Joaquin <br /> I---heMby certify that I have prepared this application and that the work will 4- <br /> County Ordinances, Stat6'Lows, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or Ham- <br /> sed agents signature certifies the following: <br /> "I coMfy,that in the pt'Hoinitince of the work for which this permit is Issued, I shall not employ any person In such manner <br /> as to become sub jeoib"% s of Wo'rk'mo I$ C07PO"30 tion lawCalifornia." <br /> Signed ..... ... n.e1 ,6 <br /> ­ %& ............ <br /> ----- . ............. Owner <br /> By........ <br /> .......(If..a...t h.e....r th.....a n_owner)----------------- -------------- .......... Title __..........­........._---------_.................... -------------- <br /> BORDEPARWAMT USE ONLY <br /> APPLICATION ACCEPTED BY ------------- ....................................­....... DATE <br /> BUILDINGPERMIT ISSUED ...................... ............................................._-----------:--------1..............DATE ...... ......... ......... ...... <br /> ADDITIONAL COMMENTS ,,..............­........ ..... ---- <br /> ................. ...........­­..........................-1-----­-------- -' --...................... <br /> ---------------------------------------------------------------------------- ----------- ------ ------------*11----------------------------------------------­....................... <br /> ......................­_­­............. <br /> ................ <br /> . . ­ - .. <br /> ­-- -- -- -................. ........ ..... . . - - -------------- <br /> ------ <br /> --- <br /> ------------------------------.-*........FinaInspection ........ N_ - - .. ........... Date ..... .... .----- .. . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 14 <br /> E. H. 9 1-'68 Rev. 5M <br /> X <br />