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FOR OFFICE USE�B <br /> / APPLICATION FOR SANITATION PERMIT f <br /> = � ------------ f I 4e Permit No. . <br /> (Complete in Triplicate) <br /> < This Permit Expires 1 Year From Date Issued Date Issued . 7713`---I <br /> Application is hereby ma�a to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This applicatioln is made in compliance with County Ordinance <br /> � No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCY�, --------------------------------------- <br /> IN 13 3 �w -- (w �1 f'-''� ...-----CENSUS TRACT ------------------------ <br /> --------------- -------------------- <br /> Owner's Name ----- -------Phone _y77-AR Y---------- <br /> Address `r - _ C(,d1-- k1 -v City <br /> -------------------------------------------------- <br /> Contractor's-Name ------ ---11-- - --------------- -------.License # fC� �/� Phone <br /> - - --- -- -- - -- - -- <br /> Installation will serve: Residence$Apartment House�❑.Commercial [:]TrailerCourt i❑ <br /> -- Motel ❑Other ----------------------- ---- -i-� ii <br /> �. N t <br /> Number of living{units:__!. Number of bedrooms ---1 .Garbage Grir`der ------------ Lot Size _________� ------------------ <br /> Water-Supply; Public"Sysl�m and name -------------------------------------------------------------------------------------------------------------Private El <br /> Character of soil to a depth of'3-feet: Sand'❑ Silt C1Clay E) Peat❑ Sandy Loam ❑ Clay Loam TX <br /> Hardpan ❑ Ado6iiT —Fill Material ------------- If yes,type ____________________________ <br /> (Plot plan, showing size f of lot, location of system.in_.relation_to .wells,,buildings,_etc., must'be placed on reverse side.) <br /> NEW INSTALLATION: I rk`' ' r <br /> Na-septic tank or seepage�plt permitted if public sewers available within 200 feet,] O <br /> PACKAGE TREATMENT.'I <br /> ,-SEPTIC TANK [ ] Size------------------------------ ____.___�-__-___ Liquid Depth _____._____-___-___.----- <br /> v <br /> { Capacity ------- <br /> --------- Type Material--' = No. Compartments <br /> Distance to nearest: Well�_` .x_�-' ---------------Foundation ---------------------- Prop. Line ---------------- <br /> ._ <br /> LEACHING LINE [ ] N�o. of Lines ---_€_______ _________ Length of each line-- .__!---------------- Total Length -____-____-___--__-___-_.__ \J <br /> I a i I <br /> Box ---------._-'Type Filter Materia! --------------------Depth Filter Material -----------------------.- ----------------- <br /> Distance to nearest: Well ------------------------ Foundation ______________ _______ Property Line ---_------_---------- <br /> SEE <br /> -_ <br /> SEEPAGE�PITI [ ] Depth ______________ _____�D.iameter_.----------------_.Number..'---------,------------------ Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size <br /> Distance to nearest: Well ________________________________________Foundation ._ ----------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------- <br /> ------------------ <br /> Septic <br /> -__-_..__.___i___.______________Septic-Tank (Specify Requirements) ------------------------ -- ------------ -- -•----------------------•----------------------------- <br /> Disposal Field (Specify Requirements) ------------aGC ----------- - ----------------------------- <br /> t <br /> ---------------------------I ----- 11--------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------=--------------------------- --- ----------------------------------------------- -----------------------=--------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I ha11 ve prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinon ces,-Statel'Laws,_ind_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 oVthe.work•for`ihtch this permit is issued, I shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed __.....__.___ 11 Owner <br /> -- ------------ - -- <br /> BY ----------------- - -- -----�I` Title <br /> --------------------------- <br /> (If other t owner) <br /> I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEDil'BY -----l'if ---- ----------- ------------ ----- ------------------------------------------ DATE Z--Z ------••- <br /> BUILDING PERMIT ISSUED ----- ---------------------------- -------DATE -------------.-----------. <br /> ----------------•-----------•--•------------------------=------- ----------------- <br /> ADDITIONALCOMMENTS - -------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> - iI <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I <br /> .: --------------------------------------- <br /> ---- ---- - - --- - <br /> Fina! Inspection b ----------------------------------------------------- <br /> -- -------- - ------------------Date r <br /> SAN OAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'a8 1ev. 5M _ <br />