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FOR OFFICE USE: F <br /> .� APPLICATION FOR SANITATION PERMIT <br /> Permit No. - '-�7 <br /> 4_- (Complete in Triplicate] . <br /> ----------1- - ------------------------------------------ <br /> _ Date Issued <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 /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> t+ Ll <br /> JOB ADDRESS/LOCATIO,N},. "t ------N---- R -----------------------------------------------------------CENSUS TRACT ----------- <br /> Owner's Name - 1_ , +M------------------- ---------------------------------------------------_---------------------Phone_A q-------._.. <br /> t Address .---___-____ <br /> ------------------ --------------- city -:sC0CXT®a--------•-------------------- ---------------------- <br /> Contractor's Name ------E �_F---.----- ----------------------------------------------------- <br /> ----.-.License # ------------------------- Phone ---------------------•----•--- <br /> Installation-will serve: Residence ❑Apartment House❑ Commercial :❑Trailet Court i❑ <br /> Number`of living units:--- ------- Number of bedrooms =-- _--___.Garbo a Grinder -- - C----- Lot Size _- ----------------- <br /> Water <br /> ->R s <br /> Motel N'Other -- -� <br /> 1 9 -- -- - ----------- <br /> Water Supply: Public System and name --------------------------------------------------------------•.--------------•--------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam:❑ <br /> E Hardpan ❑ Adobe ❑ Fill Material __ ._ If yes,type ---------------------------- <br /> (PI"ot 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,) ,)f p�� <br /> PACKAGE TREATMENT [ ] SEPTIC <br /> -�TAANK:[ ] Size---- �_ -S��ax__1_�l --------- Liquid Depth ----i---f............... <br /> Capacity _� ---%lType -------------------- Material__CC �_X__ No Compartments -- ----........... a <br /> It <br /> Distance to nearest: Well -----'0Q__--------------------Foundation -----\_0----------- Prop. Line TO--_-:..--__-_ <br /> LEACHING LINE [F} No. of Lines ---;�L---------------- Length of each line.------ ...... Total Length ----1h(7................ <br /> 'D' Box __>�_-__ Type Filter Material S__ _ K.Depth Filter Material -------- - --- <br /> u/ __ <br /> Distance to nearest: Well ----_QO__---------- Foundation ---0--------------- Property Line. ___________------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled .:Yes ❑ No �❑ \ <br /> Water Table Depth ------------------------------------------------ ` -- <br /> Rack Size.-------------------=--=•--:----- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- "Prop. Line -.___-_.----.-._------�S <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------- ------ Date .----------t--------------------.1 <br /> Septic Tank (Specify Requirements) -------------- ------------------------ - - --------------•------------ ------------------------------•.---------------------------­ <br /> Disposal <br /> ---------------------------Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> . <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition-on reverse side) <br /> I hereby certify that 1 have prepared this application and that th'e 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: <br /> "1 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 become lec� tt to W�Q{kman' mpensati.on laws of California." <br /> Signed- -- - --•------------=------------ <br /> ' ----------------------- Owner ' <br /> By ----------------- ------------------------ -----------------------------------------------. Title ---- -------------- ---------------------------------------------------- <br /> (If other than owner) ' <br /> FOR aPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - - - ----- - -- --- VN:-, --------------------------------------- DATE --- ---------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------- ---------------------------------------- ---------DATE ----------------------------:-_------------ <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------•-----------------------------------------------------------•-------------•-•---------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------- <br /> ------------------------------- ------------ ---- - ------ --------------------- ------------------------------------------------------------------------ ---- <br /> FinalInspection by- ------ ----------------- ---------------------------------------------------------.Date --/-&--a3_--�� --------•------- <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M. <br />