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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ___r!"!--- Permit No: _--------------------- <br /> (Complete in Triplicate) <br /> ­---­---------------- <br /> This Permit Expires 1 Your 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 compliance with County Ordinance 549 and existing Rules and Regulations: <br /> JOB ADDRESS/L ION __..- l l -------- ----- CENSUS TRACT X6---------- <br /> Owner's Name ... �� -- <br /> --------------- <br /> ---------------- Phone -------------- �- ^ <br /> Address _ �?.� 1 '��'..`J - - City <br /> Contractor's Name ��� _ ._-._.License Phone <br /> Installation will serve: Residence EX-p-cortment House❑ Commercial❑Trailer Court ❑ - - «► <br /> Motel ❑Other +------------ -------- -- <br /> Number of living units: Number of bedrooms _ V__ ___Gorboge Grinder ------------ Lot Size .fi-------_------ <br /> Water Supply: Public System and ndme-..n-._�______________ �_.,w_-__.__ Private <br /> Character of soil to o depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑ Sandy Loam o Clay Loam <br /> Hardpan ❑ Adobe❑ Fi I Material -----_.----- If yes,type --------------______________ <br /> ^ Ir <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) (� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if/public sewer is available within 200 feet,) loll <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size_��_�ia?_ -� ----------------- Liquid Depth _____.-.________--__..__-- <br /> Capacity _Q_ ._ Type ' _- Material.C -�7�L�---- No. Compartments ----42 <br /> Distance to nearest: Well ------_s --------------------.-.Foundation 60------------- Prop. Line <br /> LEACHING LINE 1W No. of liries ___p :.......:.... Length of ecAline" 5�r.� s_f_ Total Length 121 <br /> 'D' Box <br /> Type, Material � ___.dC�l?'Depth Filter Material ____ g_______________________________ <br /> Distance to-nearest. Well --- ..... Foundation ---/.1�-.-------------- Property Line. 5.............. <br /> _ <br /> SEEPAGE PIT Depth ___--r4-�------- Diameter -- _._ <br /> .�s� .._.._ Number _______ _________ Rock Filled Yes No 0 <br /> E Rock Size . .r ._ __---- <br /> Wafer Table Depth ` = •---- <br /> f { C <br /> ,t { w c <br /> Distance to nearest: Well _.144------------------�------Foundation --------- Prop. Line �-----------___--- <br /> REPAIR/ADDITION IPrev. Sanitation Permit s# --------------------------------- .......... Date ----------------------._--_-----1 <br /> Septic Tank (Specify Requirements) ....:---------------._ <br /> Disposal Field (Specify Requirements) --------------------------- ' <br /> g F <br /> ----- ----•------•--------...........I—--------------- I ...................I—— ----------------- ......•----------- --- ---•------------------- .....---------­---------------------- <br /> � y <br /> - . _ _ _------------------------------------------—------------------------------------------------------------------------------------------ <br /> _ _ _ _ _ _ _ _____------------------•--____--____________.-___..------___________________-----____________._.._ <br /> (Draw existing and required addition on reverse side( <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: "- 1 <br /> "I certify that in the perFormance o e work for whlch this permit is`issued, I shall not employ any person In such manner <br /> as to beco sub ctrto,rWo an' ompensatien' of California." <br /> E" <br /> Signed ------- --- ----- ------ ------- _ - - - ------------- ---- Owner <br /> By--- ---------- •• -•-•-- - - ---- ------ ---- ............ Title ------------------........... -------------------------------------,.... <br /> (If other than owner) <br /> R . AttTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ---- ------------------------------------------- DATE .._ .......... -------- <br /> BUILDING PERMIT ISSUED ------ <br /> ---- ••• ••• --- - DATE ------------------------- -------•--------- <br /> ADDITIONALCOMMENTS---------- - --- ---- ••--• ------ ------ ---------------- ----------- -------------------------------------------..----------•.-_----------- <br /> rd`:1_ ...•---•- •--- 3 ��`-•--................-------------------------------------------------------- ------------------------- --------- <br /> j— <br /> ---------------- ----------- -------------------------- <br /> Final Inspection by: --••-•-- - __Date ..-dr 7 f f '/� <br /> �JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1268 Re . 5M <br />