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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> • <br /> (Complete In triplicate) Permit No. ..:.... ......s.. <br /> ....................................................:.... <br /> �.-.� _- --- -��. . --� �• m Date Issued . .:a ....5... <br /> Thls Permit Expires 1 Year From Date Issued <br /> Application is hereby -ads to the San Joaquin Local Health District fora permit to construct and Install the work herein <br /> described. Thislapplicotion is made in comolianee-with_County-Ordinance•Na:-549 and'existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI N .............. ...........................CENSUS TRACT .......................... <br /> Owner's Name ....:.... ._.....-... ��- ::.......- .......••. Phone _ 7' j /rG <br />' Address ........ ....... /D _)' .......................................... <br /> ��ct.E-4�'._..__...�_.�._..._....... City ...._._ ._. ..-• <br /> l <br /> ..License# -.. "..`t ALM Contractor's Nome ------------- ----�_ � �;..:...........---------•---- AFH �.-- Pitone ��--------0�------= <br /> .Installation will serve: Residence*pal tment House)] Commercial❑Trailer Court C] <br /> =Motel`❑Other..._.. .........................._--•-•• <br /> Number of living units:___. . Number la# bedrooms ___�....Garbage Grinder .......:.... Lot Size ....._ �.......... <br /> Water Supply: Public System and name---•--......-•............................-•-.........__..........__........................-•----..........Private <br /> Character of soil to a depth of 3 feet: } Sand Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe fill Materiol ............ If yes,type............... ............ <br /> (Plot plan, showing size of lot locdtion of system In relation to wells, buildings, etc, must be placed on reverse side.) <br />' NEW INSTALLATION: (No septi-tanklor seepage pit permitted if public sewer Is available within 200 feet,} <br /> r <br /> PACKAGE TREATMENT [ J SEPTIC TANK f I Size----------------------------.................... Liquid Depth <br /> Capacity ype Materiol_...... No. Compartments <br /> Distance.to nearest: Well .......................Foundation .....__........_...... Prop. Line ......................?j <br /> LEACHING LIN i ' k.. 6 <br /> E [ ] No. of L nes . ...................... Length of each line.__-----__--- Total Length <br /> 'D' Box .:. . Type Filter Material ....................Depth Filter Material .............................. <br /> {distance to nearest: Well ........................ foundation Property Line <br /> SEEPAGE PIT p _. ...__ Diameter . . Rock Filled Yes ❑ 'No . <br />� [ ] De th .-- -... -Number ._...--•--•............ .. . <br /> r # •- <br /> Water Tabye Depth ---------------------------------------Rock Size --------------•--........-...... C <br /> �--�- Distancei to neatest:.Well .......................................Foundation .............. Prop. Line -�--------.....----••-N. <br /># RLtPAIR/ADDITION(Prev. Sanitation. Permit --------- ................................. Date'._•.---•.......................... <br /> ) <br /> f Se tic Tank JSpeci.fy Requirem nts) � � � <br /> Septic ( � - ........................................._... <br /> Disposal Field (Specify Requirements) �c�. . .....I............ ... . <br /> ---------------------------------- <br /> . •.... ---- -- ­­-­----------- <br /> -------------------------------- ---- <br /> md <br /> 1 hereby cerci that have�re prepared this application anon a d ithatatd =- = <br /> `;d'iton on reverse side) <br /> k y ty p p pp he work will be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and-Ru les-and-Regulations-of-the-San-Jeaquin Local Health,District. Home owner or liven. <br /> sed agents signature certifies the following: <br /> ` "I certify that in the performance of thelwork for which this permit is issued, I shall not employ city person In such manner <br /> as to become subject to Workman's Compensation laws of California.". <br /> Signed <br /> ----------..-.- ,�4 :, . ......_ . -` Owner <br /> - - <br /> 1�. .. ; <br /> 8Y ....-- ----- ---------•----•----- Title ................... ------------------------------ .......... <br /> {If r than owner) I <br /> R PIEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- 11!-.-_•-.- -- ( - . DATE......--& -.2.$' S______....-: <br /> ------• -------• ----- -------•- ... .. <br /> BUILDING PERMIT ISSUED --------------------•--- � ` '= DATE ------- - -.---------•................ <br /> .:_. <br /> ADDITIONAL COMMENTS ---•------•-----•----• � �.....R......_..} �1; r.. <br /> v <br /> I t ---ti <br /> --. <br /> Final Inspection b ............------•.... ............................Date ... ........ <br /> ' ' EH 13 2l 1- liev. SAN JOAQUIN LOCAL HEALTH DISTRICT 87)3 3M <br />