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FOR OFFICE U <br /> _. ._ APPUCATION FOR, SANITATION PERMIT <br /> ..,;� .. a <br /> • T _ - (Complete in Triplicate) ,. _..�..v,_.� ..�... __�.. ._ �. , <br /> ...... ........................................ This Pern It Expires 1 Year From Date Issued <br /> KTM Date lasued :.4? . .7 <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 corn liance with County.Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..rf..�..�._--�.... ............ .......... ... , <br /> �c.�,, ,.. ......:..,.CENSUS TRACT ......... ................ <br /> Owner's Name Vo, �-�-'`' _.,.0 . ,. .......................................Phone ......;.. ...........-._............ <br /> ............ <br /> Address . . ..,9_P-i' ...... City ........................ ...................... <br /> Contractar's- e- <br /> Nam - _ -- ,.,.. ... ,. r .... <br /> .. .. . ... ---•- -- .License ••f�M Phone <br /> Installation will serve: Residence OrApartment House'Q Commercial {]Trailer Court C3 y <br /> Motel b Other -------- ------------------------------------ <br /> Number of living units:.-.-./--__ Number of bedrooms .-..,......Garbage Grinder ............ lot Size �i .. f`� -- <br /> Water Supply: Public System and name ....._-•---------------.................................._---........------=...........................--_.....Private j> i <br /> Character of soil to a depth of 3 feet:. Sand❑ Silt j] Clay ❑ Pent❑ Sandy Loam ❑ Clay Loam.R <br /> Hardpan 0 Adobe 0 Fill Material f if yes,type <br /> E <br /> (Plot 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 1f public sewer is available within 200 feet,) �f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size.-.11-1(.i." I.6.................... Liquid. Depth ..f�_............_ ...... <br /> Capacity `•-, Lie_.. Type Material..... .... No. Compartments <br /> Distance.to nearest: Well ............................ .....Foundation ...................... Prop. Line ...................... ! . <br /> LEACHING LINE [ ] No. of Lines -- --------------------- Length of each line._ ..._....__......... Total Len th , • ��✓ ! <br /> t , ,.•.'.D'...Box..:...__-__._.Type-.F ilter,.Material .......................Depth Filter Material /.!'-•••......................•: s i <br /> Distance to nearest: Well _.`... .."� _.._...(Foundation Property Line ........ ............... <br /> SEEPAGE PIT [ I Depth __.. --------------- .`' ,.„,.�.'.�, � ❑ 0.1" <br /> i11L <br /> ----__-. Diameter»................ umber ..:.:�:.._._.... -. _. ........ Rock Filled Yea No <br /> Water Table De pth .... ...........:.:............Rock Size .............................. C <br /> Distance to nearest: Well ...... ......:..................foundation ................ Prop. Line ...................... <br /> REPAIR/ADDITION{Prev. Sanitation Permit# .._-__--"--..-------•---•-----•......•...... Date.........:.....-- .............. <br /> Septic Tank {Specify Requirements} �'. - <br /> Disposal Field (Specify Requirements) _------- - ------------------------ -------- ............-----•--•-•----_--_-----,_-............. .................,......... <br /> ---------------------I.......--•---............. <br /> � I <br /> -----------------------------------------•- -------•-------------------------•--------------------..-... .............................................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin <br /> tri t. Home owner or licen- <br /> Rul and:Regulations.aE the San Joaquin. Local Health;Dis c <br /> County Ordinances;•State Laws, and Rules.. g cl <br /> sed agents signature'certifies the following: <br /> "I certify that in the performance of the work.for which this permit is issued, IlAholl not employ any,person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed :. Owner <br /> itle <br /> qi <br /> other than owner) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYAA---- --- _ DATE__ " 1'..'-_G..... , <br /> BUILDING PERMIT ISSUED'---" --- - -- _---.�..::--....................... ... ...................---DATE <br /> ADDITIONAL COMMENTS _. . _ ._. 3 <br /> ------------------------ <br /> - -- - - - -------- - -------------•------------------------- <br /> FinalInspection bY= -- - ------- --- -; .-•-------------•••-----•------------------•--------------_._...------ Date ..... .- � T ....---...... <br /> l 13 1-6 v �; SAN JOAQUIN .LOCAL HEALTH DISTRICT 87}1 3M <br />