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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT . _ <br /> N ICompleb In Triplicate) <br /> Permit No. .... 7 <br /> . <br />............ ............................................ This Permit Expires 1 Year From Dab Hswd Date issued .. :... <br /> Application is hereby made to the Sar+Joaquin Local Health Distrld for a permit to eon*%i I` card install the work herein <br /> described. This application is made in compliQance with County Ordinance No. 549 mid SaIdIng Rules and Reguiallonsi <br /> ' <br /> ,5�5�9. <br /> JOB ADDRESS/L TION ...... <br /> � .. .....................................' � CENSUS TRACT .......................... <br /> Owner's Nam ro': ... ............. ....�7........ `......................................... ... .Phone .................................... <br /> Address .... . d.. -. 1 .............................City . ... . .. ................... .....f.. <br /> Contractor's Name .... ., .`... .... ........................License# .��.. j :!!�..... Phone ��. : .�a:.11a...... <br /> installation will serves Residence gApartment House C3 Commercial QTraflw Court C3 <br /> Motel ❑Other............................................ <br /> Number of living units:... Number of bedrooms ...,1�-.....Garbage Grinder ............ Lot an .2. 7.. ............. <br /> Water Supply: Public System and name ...............................»......................._........... ............. ..................Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt Q Clay ❑ Peat❑ Sandy Loom Q day Loom Q <br /> Hardpan Q Adobe` Fill Motorial ............If yes,typo........................... <br /> !Plot plan, showing size of lot, location of system M relation to wells, buildings, alt. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sower is availeMe within 200 feet,) ` <br /> PACKAGE TREATMENT I SEPTIC TANK IV <br /> Size..�..�:Z .:SX..��...........•• Liquid Depth ........................• <br /> Capacity ./..�(ra 0....... Type �? Moterkd.ate........ No. Compartments ......�: <br /> Distance to nearest: Well .......��..�.�..�................Foundation....1©.�....... Prop. Una..46, �........� <br /> LEACHING LINE (LK No. of Lines .......... ............ Length of each line....9.....�...... Toro) Lar�th ...`.2a........... � <br /> '0' Box ..1....... Type Filter Material Depth Fiber MsMerial ......ZS............................. <br /> Distance to nearest, Well ........... Foundation ..... Property Line ..5..(•• ..••.•••• <br /> SEEPAGE PIT (1K Depth ....a s......... Diameter ..3 ........ Number ........� ........... <br /> .. Rock Filled Yes U3--'No <br /> '00' <br /> Water Table Depth <br /> ..... . ......................Rock Silo...40 .....,?�.�.�...::::....... <br /> Distance to nearest, Well ....Z:..�}.,......................Foundation .....70........ Prop. Line .. ............... <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ................................. <br /> ) <br /> SepticTank (Specify Requirements) ......................................... ................................«....................................................... <br /> DisoosalField (Specify Requirements) ..................................................................................................................................... <br /> . ................................................................................................................................................................................................ <br /> ------•--•-•......................................•• . .............................---.......................... <br /> Draw existing and required addition onrevera sidol <br /> I hereby certify that I have prepared this application and that the work will be done M acewdence with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Leal He" Disirld.Nemo owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shah net emplop any person in such manner <br /> as to become ec to Wor an's om ensation laws of California." <br /> 'a:greed .. .. ........... P .. ............. Owner <br /> By ..... ............. c ,G .. .. ................... dills ....... "'`7.<•..................................................... <br /> (If other than owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYE -.. .............. <br /> : ............... DATE-;........? 3.�........ <br /> BUILDINGPERMIT ISSUED .............................................. ...................................................... .. .................................... <br /> ADDITIONAL COMMENTS .. .................................................. <br /> ... --•--.......... ............................................................................................... ......................•--........................ <br /> ............... <br /> .. ................................................................................................................. .................................................. <br /> ................................ ................. .............-- <br /> _. <br /> FinalInspection by: ..--•--------•...............................�. .... .. .........--- .......... ..........................Date r�`....�.:. ................ <br /> EN 13 211 1--68 Rev. 5q1 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br />