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FOR OFFICE USE: <br /> ----------- -------I----------- ------------- APPLICATION FOR SANITATION PERMIT` <br /> ----------------------- J .(�omplete in Triplicate) 'Permit No, <br /> - -------------------------------- <br /> -------------------------- --------- ----------- -- This Permit Expires 1 Year From Date Issued Date Issued <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 complianceou �rdi 71/No. 549, ancl'`exi Rule's and Regulations. <br /> JOB ADDRESS/LOCATI <br /> ------- ------------------------------ ____CENSUS TRACT <br /> Owner's Name _,/- -- -- --------- ------ <br /> - ------------ . <br /> OSD- <br /> ----- ----- ---------Phone --------k <br /> --------------- <br /> Address ----------------- - ------------- Cit <br /> Contractor's Name <br /> ---- --Q --------- Ves e �_�P one --- - ------ -------- <br /> e - 1- -- -- --------------------------Lice se <br /> Installation will serve.. Residence HouseE] Commercial:OTrailer Court ❑ <br /> Motel El Other --------------------------- -------------- <br /> Number of living units:----/----- Number of bedrooms <br /> Water ��_%'LGarbage Grincer/PD--- LotSIze <br /> -j ---------------- <br /> Supply: Public System and name ---- --------------------I <br /> ---------- ------------------------------------____Privateer' <br /> ---Private J;j� <br /> Peat <br /> d'' <br /> racter of soli to a_depth of 3 feet, Sand Clay at Sandy Loam ay Loam f-1 <br /> Hardpa'n E] Adobe-[:] Fill Miaterial X71-- If yes, type ------------------ --------- <br /> (Plot plan, showing size of lot, lo,cation of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic I tank or,seepage pit 1permitted'if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK: I <br /> ty f-;4, o o--,-*--- --------------- Liquid Depth ---- <br /> C&pacity:_1.,------ ----------- T-- 4 - /)�-- <br /> ype MateriA�J�Cax_,�_ No. Compartments ------- <br /> Distance to,,nearest. ,Well ------------ Fou' riclation .../-0--/----- Prop. Line <br /> - --------- Length of OTotal Leng c) <br /> LEACHING LINE No. of Lines - I " - Length <br /> ) e I ------ <br /> I I ---------- <br /> 'D' Box e�4 Type Filter Material - 7' 1! <br /> pth Filter Material ---- <br /> ---------------------- <br /> Distanceyo- nearest: Well'74V------------� .Foviriclation--:t_�Z0 <br /> ------ Prop" Line _/41--------------- <br /> SEEPAGE PIT Depth -------------------- Diameterumbe <br /> ----- N ? <br /> - , L I - Rock Filled Yes ❑E] No ,C3 <br /> 4 <br /> Water Table Depth ------ <br /> ------ --------- 'Rock Size <br /> - -- - - <br /> ---------- --------------------- <br /> Distance to nearest- Well ------- <br /> ------ ------------ -----------Foui�da_t_ion—----- -------------- Prop. Line ---------------------- <br /> F�e_v. Sanitation Permit ------------ ----------------- Date ------ <br /> REPAIR/ADDITION( 1% 4' <br /> 1 1 1 \. <br /> --------- <br /> . =-', <br /> , - -------------- <br /> Septic Tank (Specify'Requirements) -------------------------- <br /> ---------------- ------------ ----------------- <br /> ----------A---------- ---------------- ---------- <br /> P <br /> Disposal ;Field {Specify Requirements) ----- <br /> _T__ro <br /> -------4_13cojz�� ---- ---------------- <br /> 14-& ---------- 4 <br /> ------------ <br /> - ---------------------------------------------------------------------------- ------ --------------------------------------------- <br /> (Draw existing a6d required addition on reverse side) <br /> I hereby certify th6t I 1have prepared this application -and that,the work will be done in accordance with San Joaquin <br /> COU <br /> nti_d_rdiWanc"is_, §tate laws, and Rules and Regulations of f 14.San'Jouquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I that in the perF*rmd f certify the work for which this permit is issued, I shall not employ any <br /> y j person in such manner <br /> as to'beco SuPle t to Wo M 's C, <br /> I 40*ensation laws of California." <br /> Signed __ - + . <br /> ------­ -- ­:��C)Wn—er <br /> By --- --------- --------------------- ---- --- ---- ------------- --- ------------------------ -Title <br /> (If other t owner) ------------------------------ <br /> If, FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ? ------ - -- -- -------------------------------------------------------------------------- DATE ........ <br /> --- --------------- --- ---BUILDING PERMIT ISSUED ----- -------------------- ------------------------------------------------------------------- -------DATE ------------- <br /> L COM TS <br /> ADD11TIONAL COMMENTS -- ---- -------------------- -- ----- - ----------------------------------------------- <br /> ------------------------------------ <br /> ------------------- <br /> _ <br /> ------------- <br /> d-�,_-- _-_----- ----------------------------------- <br /> ___ _. r------I---------------------------- ----------------------- - ------------------------------- --------------------------------------------- <br /> -------------- ------- <br /> 4------------------------- - ------- ------ ------------------- ----------------------- ---- ----------------- <br /> z- /�-------- <br /> Final,lnsp --------- <br /> Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. I tJ j <br />