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FOR OFF Cl�USE: � <br /> APPLICATION FOR SANITATION PERMIT lid 7 <br /> ��.-�.;,. Permit No. - --- --`- ----- <br /> --- -----------------------------•-- ------------------ �r�.;. (Complete in Triplicate) <br /> ------------------------------------ ----------- --------- --- This Permit Expires 1 Year From Date issued Date Issued <br /> --------------------------------------------------------- <br /> , <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 /> 1 <br /> / Y `'V CENSUS TRACT L----------- <br /> JOB ADDRESS/LOCATION ._.L- _-=- - <br /> L,rH�f,.Ulil?�x 1P7 C41�----------------------------------- ----- -------Phone ----------------�---- <br /> Owner's Name _._�_ . ��--"""- --" <br /> Address "-------------MOCK_-��_t. �- -----• City I?)A•? 72ACY--------- ------------------------------------------ -------- <br /> -------- Phone -------�`---------------- <br /> Contractor's Name -------- QLI�fZ."----- --�-- p------- ------------- - -❑ ❑ <br /> ------- --------License # ---------.- <br /> Installation will serve: Residence Apartment House Commercial: Trailer Court C1 <br /> Motel ['Other -- � O_*C-f4------------------- --- <br /> Number of living units:__ Number of bedrooms-------Garbage Grinder Lot Size _____ <br /> _ ------- - --------------•----�-Private <br /> Water Supply: Public System and. name _______________________------_ („ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Cl Clay ❑ Peat❑ Sandy Loam ,❑ Clay Loam.[] <br /> Hardpan ❑ Adobe' ill Material ------------ If yes, type ------ --------- <br /> I <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,] y` <br /> Size---------- • Ci' ------ --- Liquid Depth ------ ----------.----- <br /> PACKAGE TREATMENT ( ] SEPTIC 7ANK'[�]' - --`" - <br /> yp __ Material.__==- No. Compartments <br /> Capacity _: 7 e <br /> Distance to nearest. Wel! -----J ----------------------Foundation -----/ ----------- Prop. Line _f -:-------- <br /> len th of each line-__ --------------- Total length ---- ----------- <br /> LEACHING LINE [ ] No. of Lines ------/------------ 9 <br /> 'D' Box "--3------ Type Filter Material ° -----Depth Filter Material ----- <br /> - � � - <br /> �� _ .: � --w �d Pro er Eine <br /> - -- '�'` Distance to nearest: We "_,__ -4.-J" °'" -'�Foundafion ----------------- p tY <br /> SEEPAGE PIT [ ] Depth _____ Diameter ________________ Number ------ --------------------- Rock Filled Yes ❑ No I❑ <br /> Water Table Depth ----------- ------------------------ <br /> -------Rock Size --- ---------------------------- <br /> ,. Distance to nearest: Well ----------------------------------------- -------------------- Prop. <br /> i <br /> ) Line -------------- <br /> n Permit -""""--------- -------- ------------------- Date ---------------------------------- <br /> REPAIR/ADDITION(Prev. Sanitatio <br /> Septic Tank {Specify Requirements) ---- ----- - <br /> k ---------------------------- <br /> Disposal Field (Specify Requirements) ----------- ------ <br /> ------------------------------------------------------------------ <br /> -------------------------------------------------- ------------------------------------------------- <br /> F <br /> - - --------------- ------------------------------------------------ <br /> ---------------------- <br /> ------------------------------------------------- <br /> -------------------------------- - - - <br /> (Draw existing and required addition on reverse side) <br /> I red this application and that the work will be done in accordance with San Joaquin <br /> I hereby certify that I have prepa <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: <br /> "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 beco a subje to Wo cg's C sation laws of California." <br /> Signdd <br /> Owner <br /> - ---------------- ------------------- <br /> -------------- Title --------------------------------------- ---------- ------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT S L — <br /> APPLICATION ACCEPTED BY ----- ------------------------------------ ------------ ---------- - -- <br /> --- ------- --------. DATE --- --- - �� - - ------ <br /> DATE -------------------------------- -----•---- <br /> BUILDING PERMIT ISSUED ------------------------ ---------- ----------- <br /> ADDITIONAL. COMMENTS - ------------------------------------------ -------- ------------ ----- <br /> -- -------- -- -------------------------------------- <br /> --- ------------------------- --------------------- ---=------- <br /> 4 _________ _ _____________ ____________ <br /> Final inspection b <br /> -------------------------------------------- <br /> - ------Date `j�"t'a-�Y) <br /> ' SAN JOAQUIN LO L HE RICT <br /> E. H. 9 1-'b8 Rev. 5M <br />