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FOR-OFFICE USE: APPLICATION FOR SANITATION Pr <br /> Permit No. ----------------- <br /> -- ------- <br /> ------------ <br /> ----------------------------------------- <br /> (complete in Triplicate) Date issued <br /> ------------------------------------- <br /> ------------------ <br /> This Permit Expires I Year From Date issued <br /> - - ---- <br /> Application <br /> : work herein <br /> I ereby made to the San J aquin Local Health District for a per!nit to sex <br /> and install the <br /> '\Appli.-ation is nty ordinance No. 549 and existing Rules and Regulations: <br /> descrAEd. TrhA de i m liance with COu <br /> _CENSUS TRACT -------------------------- <br /> --------Ph ---------------- <br /> JOB one <br /> ----------- <br /> --------------------- <br /> -------------------- <br /> OwIner's Name' ------ <br /> 7_7------ ----------- ----------- City _-Ac-te? ------------------------------ <br /> Address --------- ------ <br /> Contractor's Name -------- -- ---- ------ ems:-------.License # Phone ------------------- <br /> Insto'llation will serve.. Residence E] Apartment House❑ Commercial []Trailer C <br /> Motel ❑F-1 other -------------------------------------------- <br /> Lot Size ----------------- <br /> Nun'�ber of living units I/_ Number of bedrooms ---11-------Garbage Grinder ------------ <br /> Private <br /> ------- ----- -- <br /> -- -- --- --------- <br /> Water Supply. Public System and name -___----------------------•-----•Clay-y-_F1-----Peat F❑ <br /> -------Sandy Loam E] Clay Loam <br /> .,.,Character of soil to a depth of 3 feet. Sand'F� Silt 0 1 ---------------------------- <br /> Hardpan f-1 Adobe ❑ Fill Material ------------ if yes,type <br /> must be placed on reverse side.) <br /> (plot.. plan, showing size of lot, location of system in relation. to wells, buildings, etc. <br /> itted if public sewer is available within 200 feet,) <br /> NSTp <br /> NEW INSTALLATION: (No septic tank or seepage pit erm <br /> --------- )._cf __r ------ ---- ------ Liquid Depth -----�/----------------- <br /> Size- .----- ------- 2 <br /> PACKAGE TREATMENT SEPTIC TANK ents ----- <br /> ity -YaQ------ Type Q _U2 No. Compartm <br /> F <br /> * <br /> Capacity Line ---------------- <br /> �e- ---------- Prop. <br /> to nearest.. Well <br /> Foundation <br /> Distance If , i �6 _ Total Length <br /> ---- Length of each line <br /> LEACHING LINE No. of Lines -------------------- <br /> X V Box ------------ Type Filter Material ------&4/�__Depth Filter Material __11_1T--------------------- <br /> t—Di�ta­nce- to nearest: Well ------------------------ Foundation ------ ----------------- Property Line- --------------- <br /> Diameter ---------------- -Number ---------------------------- Rock Filled Yes [3 No <br /> SEEPAGE PIT [ I Depth ------------------ <br /> RockSize ----------------------- -------- <br /> Water fable Depth ------------------------------ -------------------- Prop. Line ---------------------- <br /> Distance.to nearest: Well - --------------------------------------Foundation <br /> --------------- <br /> Date ------------ <br /> - <br /> P <br /> - <br /> t <br /> REPAIR/ADDITION rev. Scinito ion Permit# ------------------------- <br /> ------------- ------------------------------- ------------------- <br /> Septic Tank (Specify Requirements -------------------------- <br /> ------------------------------------- -------- --------------- <br /> Di;posal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------ --------- <br /> I - r" - ----- ------------------------------------------- <br /> �r 1-4 11 ----------------------- ---------------------------------­____ <br /> -------------------- A----------------- ----------------------- ----------- <br /> ----------- <br /> ---------------------------------------------- <br /> ------------------- <br /> ------ <br /> ------------------A_--------- -1-------------------------------- ---------------------- <br /> (Draw existing and required addition on reverse side) h Son Joaquin <br /> and that the work will be done in accordance wriu <br /> I hereby"certify'tk;t I have prepared this application <br /> County ordinances, St-ate Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> L <br /> sed agents signature;certifies the following: <br /> "I certify that in,the perForma c of the ork for which this permit is issued, I shall not employ any person in such manner <br /> as to be 0 s . ct t or n's Co P"ns tion laws of California." <br /> ---------- Owner <br /> Signed - ---------- ------ ----- ------ -- - - -- ---- ------------ ------ -------------------- <br /> - ----------- -Title __.-------------- --------------------------- <br /> By -------------- <br /> (If other than ow er) <br /> , <br /> FOR DEPART T US N <br /> N47� <br /> - - ---- ---- ----- L- - -------------- ------------ DATEE ------ <br /> APPLICATION :ACCEPTED BY �--------- -------------------- -- --- --- - - --- --------DATE ------- <br /> ------------------------------------------- <br /> --------- <br /> - <br /> BUILDWG <br /> PERMiT,ISSUED--- ---- -------- - ------------ ---------------------- --------------------------------- <br /> ADDITIONAL COMMENTS - ----------------------------------------------------------------- - ----------------------------------------- <br /> --- - ------- -- - ------------- - ------------------------------------------------- - ------------- <br /> -------- -------------------------------------- ----------------------------------------------------- <br /> ------- -- ---- -- --- - ------ -------------- -%_ /-------- - -----?.- <br /> -- ---------------------- ---------------- --- --- - -- ----------------- --------- <br /> ----- -------------- --- --- ----- ------ <br /> ------------------------------------------------------ - ----- -- --- - --- ---------Date.- <br /> - ----- - -- ------- I ------ ------------------------ <br /> Final Inspection by-- --------------------- ------ --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT \ \ <br /> E. H. 9 1-'68 Rev. 5M <br />