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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> sal . (Complete in Triplicate) Permit No. ...... ...... <br /> .....'.�.t3v1�r---.. ..�.r :. This Permit Expires 1 Year From Date Issued Date Issued .1c ..:: -7.. <br /> Application is hereby made to the Son 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'. 544 and existing Rules and Regulations: <br /> JOS ADDRESS/LOCA TION ... .I.. ..L .t__. T.!��.: -------------• - <br /> ..........................CENSUS TRACT _....---------••------ <br /> k <br /> Owner's Name .................................... 9ze�o.. �`aC1.�J<.l: !e. . ............. ............Phone <br /> R <br /> Address t.. 1.. �7 �......•-•--• ------. <br /> .............. ..1...�.....:��] � ---....... ....... city ..�..�.... _�..............----..:-•--••-•---------•--........:... <br /> Contractor's Name ... `J�:. tiA. a.................... <br /> ..S .......-License # ........................ 6tS—f 6 4 <br /> Phone ... <br /> Installation will serve: Residence Apartment Hoiise 0,Commercial❑Trailer Court ❑ <br /> Motel ❑Other-------------------- ---------- ----••---- ' <br /> . Number of living units:..:!........ Number of-bedrooms .......Garbage Chin er ......--.:.- Lo Size fa.�..6. ...................�... <br /> Water Supply: Public System and name ............ ff ll ] <br /> ........................................... .........Private ❑ <br /> Character of soil to a depth.of 3 feet: Sand❑ - Slit❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Of <br /> Hardpan❑ Adobe Fill Material ............ If yes,type............................ <br /> IPIot plan, showing size of lot, location of system In relation to wells, buildings, etc.,,must be placed on reverse side.) <br /> r, NEW iNSTALLATION:. (No septic tank or seepage:pit permitted if publ€c sewer is available within 200 feet,) k <br /> PACKAGE TREATMENT ( ] SEPTIC TANK{ ] Liquid Depth <br /> Size.......:.................. ............ ; <br /> Capacity •---•--------------- Type --•-• --- -:- Material...................... No. Compartments ................ <br /> Distance to nearest: Well ._.Founid6tion ............ Prop. Line ....................... <br /> LEACHING LINE { ] No. of Lines ........................ length of each line...................... Total Length ............................� <br /> N <br /> 'D' Box :........... Type Filter Material ....................Depth Filter Material ........_.... <br /> ....................:.. _. <br /> Distance to nearest: Well ....................... Foundation ........... Property Line .................... �0 <br /> ..." <br /> SEEPAGE PIT [ ) Depth ..................... Diameter ........... Number ............................ Rock Filled Yes ❑ No ('] <br /> Water Table Depth ..............................................Rock Size ................... <br /> Distance to nearest: Well .................:......................Foundation ..................... Prop. Line ....................... <br /> REPAIR/ADDITION IPrev. Sanitation Perm ............ .......... ------------- pate .............. . .......... .I <br /> Septic Tank (Specify Requirements) ! ¢ _, . <br /> Disposal Feld (Specify Requirements) .................. ............................. <br /> t ° <br /> ----------------••_..........-•---....------•--....---•:......_,............---....................__1.1!.............. <br /> . . -. . <br /> 1• Drow existing on&required addition on reverse side) i <br /> I hereby .certify that I have prepared thls application and that the 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 liceniL . <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 bec a su 'ec o Workman's..Cpmpensat o la s of California." <br /> Signed <br /> ............... -•--•- <br /> ........__ <br /> By ..---. .............:.:...... ... . ..�. . ..�---..�... , tie � - --------......-------. -- ------ l <br /> (If other.than owner) <br /> F DEPARTMENT WE ONLY <br /> APPLICATION ACCEPTED, BY --- •-- . ........................... .�-- <br /> <. .�: DATE .. ...... ... <br /> BUILDINGPERMIT ISSUED� -•• ---------------------------------- -----------------------•----.--•--.-•...............------.....DATE ..........---•. ........................ <br /> .. <br /> ADDITIONAL COMMENTS .......I.—.......:.:............... <br /> - :......:.... <br /> ................... ............. :.... ....---•- ...................................................................... <br /> Final Inspection by: .............. ..U`��� Date '' <br /> ......... .. ....•-..... <br /> r. <br /> S JOAQUIN L HE TH DISTRICT <br />