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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ... ..................................... ' Zil; Permit No. ...7�/_l.`-a <br /> (Complete in Triplicate) <br /> I Date Issued 3. ZY� <br /> ......................................................... This Permit Expires 1 Year From 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 /> j. described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI K/Q2.1. '.W ,. _10,0Z .k ......................................CENSUS TRACT ----------.............. <br /> .. <br /> i Owner's Name ......-._. ~ <br /> f _._..Phone��a�f Z <br /> Address . _-..... p-'. .. City .... ......_.... <br /> ... <br /> Contractor's Name ............ . ¢a.--S&FI-W .- ------ -----.License # `f.-�� 3..._ Phone � _7.r�6d T.... <br /> Installation will serve: Residence Apartment House-E) Commercial [-)Trailer Court ,❑ <br /> Motel ❑ Other .......................'--------.. I:._ <br /> Number of living units:.:.. Number of bedrooms __...Garbage Grinder ras7jNof"Sire ......_.:...... _.......... <br /> . <br /> Water Supply: Public System and name .........•--------------------------------------------------- ........ '. - ............ ........Privateg <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam K Clay loam <br /> Hardpan ❑ Adobe E] Fill Material ............ If Y s, type .......................... . <br /> (Plot plan, showing size of lot, location of-system—in_relation-to_wells,buildingg,etc.- must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewerfis avail ble within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size.--- � _ �f <br /> ., <br /> -- --��.--'--'....... ...... Liquid Depth ._�r1-�.._...._-...... 46- <br /> Capacity/.IW <br /> Capacity/�Ci'� Type - .V----- Material.__ lcl.f.. No. Compartments ----y...... <br /> •----� <br /> Distance to nearest: Well .......... ................ undation Prop. Line -- <br /> LEACHING LINE P( No. of Lines - ._._ -.- _ Length of each#111ne� ........ Total Length <br /> D' Box .._.. _.... Type Filter Material .4_z:;4__. Depth Filter material ... .2C... <br /> ________________------__ , <br /> Distance to nearest, Well -,..._ �f -._.__ Foundation /A'7 7_,._..�. Property, Line -__-_----__ <br /> Nu <br /> SEEPAGE PIT [ }. Depth [] CV <br /> .. .....,..� Diameter ...----'-....- . tuber ._..... ..................: Rock Filled Y�s No <br /> Water`Table Depth! ..........----------------------:-./--------Rock Size -..........._ ................. <br /> Distance to nearest:)Weil_ .r. .. .............F.oundat.ion___.._. „­:--Prop..-Line ...................... <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ------ _...4-....-p.................:.... Date --------------------.-__---------- <br /> I �q <br /> Septic Tank (specify Requirements} ..... <br /> ................... tic --------.._...----------------..---------------.------------...------------._....---------------- <br /> Hi <br /> �- <br /> Il <br /> Disposal Field (Specify Requirements) ----- <br /> -------------- <br /> _'-S � <br /> hereby certify that I have prepared this application ist ” .... . " -...... <br /> d required addition on reverse side) <br /> y y p p an that the work will be done in accordance with San Joaquin <br /> County Ordinances, State laws, and Rules and Regulatidns ofithe San Joaquin local Health District. Home owner or licen• <br /> sed agents signature certifies the following: 0��.r. a� <br /> "I certify that in the performance of the work for which this permit is;issuedr I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California. <br /> Signed . qq ..... _...,.. �L i---------------• Owner �- <br /> By .../ ,�' `..... -----------------------�....--- Title . ... .`'" `�.....----._..._.. ...... ....... . -'.----....---'-- <br /> (If other n owner) # t <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... . . ...... ....... f-- -------I....... '--... ..-- ----' .... DATE _— <br /> BUILDINGPERMIT ISSUED ................ .._..:.....- .._ .......... ......--(.._._ .._.- ._.. .. ._..,......_..D TI .-. ..-.-......_.__.......-................ <br /> - <br /> ADDITIONAL COMMENTS ...../._J ...y't...-.......... ... .. ...---_.. .. -`'---- Sr -.p. <br /> ..._.-.__..- yt <br /> .-._._.__... ^. .. ..._......... <br /> .......................•-------. ,i . . - .. --7- ---------•.................. .......... .... .... ­­............... <br /> I k _... <br /> Final Inspection by: ........... �� r� Date = " ....... <br /> i SAN J AQUIN LOCAL HEALTH D15 RICT T <br /> F w 13 241_'AAD.,, 5M �"f' �� i� ��� 7/723M <br />