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FOR OFFICE USE:
<br />4APPLICATION FOR SANITATION pERMrt
<br />.....................,............................... (Cormpletein Triplicate) Permit No.T'."�...
<br />............................................ This Permit Expires I !tom From bass Issued Hate Issued .?:7:
<br />Application is hereby mode to the Son Joaquin Locos Health Dithit# for a permit 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 />JOB ADDRESS/LOCATION°;i'.x.........Ci1SLl
<br />Owner's Name ........ .....!.l•.L« .... S TRACT ..................... .....
<br />...
<br />Address
<br />w..........................«......,.. ,.......... *,....,...Phcme ....... w,.....,,...,..,..,«....
<br />Contri ,/ '...........-..... City........._00e ................
<br />actor's Name ,. _....... ... ..................f....r�- ......... ......LIcense #
<br />alt►n+e
<br />Installation will serve. Residence Apartment House fD Commercial oTroiler Court �
<br />Motel [] Other
<br />?Number of living units: Number of bedrooms ..... !�...:Gorbage Grinder ........... Lot Size ..._ :! "....:
<br />rRs..
<br />Water Supply: Public System and name............ .......... ....... ......... ............. ...._................ ...._....,..............,._,«....,,.Private i0'
<br />Character of soil to a depth of 3 feet; Sand 0 Silt �} Clay E] Peat (] Sandy Loam [. Clay Loam —
<br />Hardpan Q Adobe Q Fill Mo* terial -..... -.... if yes, hype
<br />;Plot plan, showing size of lot, location of system in relation to welts, buildings, etc. must be placed an reverse side.)
<br />NEW INSTALLATIONa (No septic tank Or seepage Pit permitted if public sewer is available within 200 feet,)
<br />PACKAGE TREATMENT [ ] SEPTIC TANK ] Sure,.................................... Liquid De
<br />Capacity . .. ... .... Type ......... ......... Nlatariasl......... .... ,..-.... No. Compartments .......,........»...
<br />Distance to neorh. Well .., _..,.. Foundation ........ Prop. Line
<br />LEACHING LINE [ ] No. of Lines ., .. Length of ................ ......... .............._. T ...................................,... �.
<br />each ilr�e Total Length__.
<br />'D' Box ..... Type Filter Material ....................Depih Ir JW 0draterial ....
<br />Distance to nearest. Well .._................... Foundation
<br />.. _,......,...,..... Property Lime ..,.,..,................,
<br />SEEPAGE PIT { ] Depth . Dicii'neter ................ Number ...... Rock Filled Yes Q to 0
<br />Water Table Depth ... ......... ..._...... »..................... Rock Size....., ...... -........
<br />Distance to nearest; Well ......,.,..._....:...................! oundatkit #hrslt =.,.._... ,..,, ..
<br />REPAIR/ADDITION (Prev,Sanitation Permit # pate
<br />...."_ _r .,,...._.,.,_............. ...................... ...........
<br />)
<br />Septic Tank (Specify Requirements)
<br />,... ... ............... ...,�.,.
<br />Disposal Field Requirements) ................
<br />� ......
<br />.......
<br />........
<br />..
<br />"o-111
<br />r « ,......., .'.�_ ..�....,...V_ `....,... ` ....
<br />. ���'���� s (Dra+sr existing and required oddiFti-cx► on reverse side)..................._..�..¢.........�.,.
<br />I hereby certify that I have prepared this application +scud that the work will be done In attordanat with San 4"4uin
<br />County Ordinances, State Laws, and Rules wW Regulations of #6 Son Joaquin, Lobed health Distritl. No" owner or il"*
<br />serf agents signt", re certifies ths+ followings
<br />"I certify that in tho parformancs of the vt*rk for which this pormit is issued, II +bray mat w npley any Person in such rasanrwr
<br />as to become subiect to Workrnah s CormPesnsotion caws of Wifetmin."
<br />Signed . .
<br />Owner
<br />by
<br />...-+-
<br />{if other than owner)
<br />FOR DEPARTMENT USE ONLY
<br />APPLICATION ACCEPTED 8Y
<br />..
<br />DATE ...., � .eti
<br />BUILDING PERMIT ISSUED..-- ...,. ..._ .. ....,.................
<br />ADDITIONAL COMMENTS
<br />.:::.:::..:.._....i}ATE..`............::.._..
<br />..................... ..........._......... .................,......., — ........................... ... a .. .x.1
<br />Final Inspection by: .............. ...... .,._...................... ,.............................. « ..........
<br />.........................................................:..........,.,.. Dots ...... j.. ,.. �, .....
<br />SAN JOAQUIN LOCAL HEALTH DISTRICT
<br />GO
<br />71
<br />. 1372 3 ,�,J✓
<br />_._ 'XL
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