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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT pp`` <br /> ........................... <br /> Dfo <br /> (Complete in Triplicates Permit No, .. .... . . ....... <br /> ...... This Permit Expires I Year From nate 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> e <br /> JOB ADDREss/LOCATION,9..1. Z. _,�.... 1 L.� `.--1�:, ..._,_. .1.PQ CENSUS TRACT <br /> Owner's Name X11 '�9 L �J Z3 ' P <br /> v� ------------------ :... one <br /> oe.c......... ..... <br /> Address ...... ... 1-- ........................................... city f1. ......... _ .......... <br /> /� <br /> Contractor's Name ..... �cr... _.-[1a_e�....................................,-`:`License #a � 'a� L,. Phone a� 9% ._....,.._...._ <br /> Installation will serve. ResidenceL�Apartment House❑rCommJ <br /> erciai :❑Trader Court C] <br /> Motel ❑Other ................. <br /> Number of. living units:------.�_.- Number of bedroomsGarbage Grinder. .__.__..-lot Size ..._._ ..y <br /> - _... --•---....... .. <br /> Water Supply: Public System and name . ' <br /> - -•----------------------------....----••---•.. ....-----••--- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ C14 171 Peat^❑ Sandy Loam t& Clay Loam <br /> Hardpan ❑ Adobe,E] Fill Material -_----.--- If yes, type ._ ..__.•_----.-. <br /> : t <br /> (Plot plan, showing size of lot, location of system'4nl relation4,to-wells, building must lbe placed on reverse side.) <br /> NEW INSTALLATION: E <br /> {No septic tank or seepage pit permitted if public 3ewer.is avoilable�within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] y Size.:.' • <br /> .4,. - - Liquid -Depth ---•----•................ <br /> Capacity <br /> yR Material--- ------- No. C6Mpartments ......................... <br /> PO'�,........... <br /> Distance to nearest: Weli Foundation....__.............. prop Line <br /> LEACHING LINE [ J No. of Lines ......................... .Length of e ch .line.. Total l Length <br /> ..- ------•--------• - { ......... <br /> 'D' Box <br /> ..... Type Filter Material ";. i <br /> r...;Depth Filter Material:0...................................... <br /> Distance to nearest:' Well Fouridat oii �-- .-Property Line <br /> SEEPAGE PIT [ { Depth ..................... Diameter -----------fl- Number ,...::.-~=:------.4 ''­-.Rock +Filled Yes ❑ No �( <br /> �..�.�. <br /> Water Table Depths--------------------------- ------- -Rdcl�Size=". . .. ---- <br /> Distance <br /> - <br /> 10 <br /> Distance to nearest: Well --------------------2-..=.--•--_----:`. Foundation ;..-..__..__... Prop. line <br /> F o ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# ....... _ <br /> •--�---- - _..:.13ate_-.--.�:.....�-:..-•-------------) <br /> Septic Tank {Specify Requirements) !�-0,.---....__./�_._.• <br /> Disposal Field {Specify Requirements} ---- 'A------- ..............••- •--..__....._ ...................... <br /> •-- --- `....................... �_s;l <br /> -- =..........--...................... <br /> _ .........................`----------•------....._-----------'....................-.....__.._......_........._.._...__. <br /> (Draw existing and requited addition on reverse side) <br /> I hereby,certify_that I have prepared this application and that,the work will be done in accordance with San Joaquin <br /> County &rdiWances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following.- <br /> "I <br /> ollowing:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner ' <br /> as to becomesuble to orkman's Compensation laws of California." <br /> Signed ...-4.r _ <br /> . .........................-.......................... Owner <br /> By ..................................... ....... <br /> --.... ......................••--••........................ Title ................ <br /> _(If other than owner)_y...,,,T _., Y. .. _ _ ..-;-�---�----------------------• <br /> FO EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. _: --,�--- - ............ ....... DATE .. _. --• -----. ., <br /> BUILDING PERMIT ISSUED ------ - -------------- ---.----DATE .__ . <br /> ADDITIONAL COMMENTS .. ..................................... <br /> T <br /> -------------- � ....................................... <br /> Final inspection by: .-- - ... .. ........Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c u 13 24 <br />