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.POR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br />......................................................... .� (complete in Triplicate! Permit No.0... .. .............. <br /> ............. <br /> Date Issued ....;............... , <br /> This Permit Expires 9 Year From Dab 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: t <br /> m <br /> JOB ADDRESS/LOCATIONw9t�,�..�.�.- '2..... .. X.. .:............: E.', i.'.*-:CENSUS TRACT ..... :4�..........� <br /> Owner's Name ........ C� ' c/ ..... .............. ... ............................ ..Phone '' . .. ! <br /> Address ... ?a!!' -.......-•---.......-•--•..................................................City .....� ..R4:� .................................... <br /> Contractor's Name ......aal?T ...............................-----..................License# .. ././21. ..... Phone .............................. <br /> installation will serves Residence Apartment Houser] Commercial QTrailer Court 0 <br /> --- Motel❑Other................n.......................... <br /> Number of living units:... Number of bedrooms Garbage Grinder . Lot Size �. �'�`-� <br /> .... <br /> Water Supply: Public System and name ..................................._...................._......._.........................................Private . 1 ... <br /> Character of soil to a depth of 3 feet: Sand o Silt o Clay ❑ Peat[) Sandy Loam day Loom ❑ <br /> # Hardpan Q] Adobe o FNI Material ..........:.If yes,type............... ............ <br /> !Plot plan, showing size of lot; .location of system in relation to wells, buildings, etc. must be placed an reverse side.)( <br /> y1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> t A <br /> r PACKAGE TREATMENT ( } SEPTIC TANK>j } t J a41 Ns Size............................, ::::........... Uquld epth .......................... <br /> e <br /> IS <br /> Capac .................... Type. .............. Mated No Comportments .. ......,...:...... <br /> D111ance to nearest: W .......................... .........Foundation ...................... Prop. Line ........ <br /> / ?r........... <br /> Pr <br /> :LEACHING LINE [ ] No. of Line: Length of each line. V:. g st:• --•••-----•-. <br />. .. ............. ..... ....... . Total Len th .... _ <br /> . --4 . CD--8ox ../ ..... Type Filter MaterlallYz:'2..........Depth Filter Material � .... <br /> ® ♦ ! r <br /> Distance to nearest: Well ..'510.......... Foundation /L?..7e......... Property Line ....�.7 ........ <br /> •SE€RAGE44T Q,.] ; Depth I.X.,?...... Dictmoor-/50. Number ../.................. Rock Filled' Yes jK No <br /> Water Table Depth ................................................Rock Size <br /> «F Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................. Date .................................. <br /> SepticTank (Specify Requirements) ........................ ............ ... ... ......................»...................... .................................... <br /> DisposalField (Specify Requirements) ................................................... ....................................................................... <br /> ..............................................•--.................................----•-•-•............---........................... <br /> ...... ...................• -•--... ..... --••. ...........---.......................................:......................... ......... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this applicallon`and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or ligan- <br /> sed agents signature certifies the followings <br /> "I certify that in the performance of the work for which this permit is Issued, 1 shall not employ any person in such manner <br /> as to become subject to Workmgn's'Compensation laws of California" { <br /> Signed ................:......................................................•--....................... Owner <br /> By ................................:..............................:.....••........ ......._.........litle ........................................................................ <br /> (If other than owner! <br /> F DEPARTMENT USE ONLY ., <br /> APPLICATION ACCEPTED BY ..... . ...... . :: .... e.. .......................—.............................. DATE . ..,�. .., ..... r <br /> BUILDINGPERMIT ISSUED ....... ...........:.. ..................................::......................... ........ .........DATE%................................. . <br /> ADDITIONAL COMMENTS .� .....................:. ..........:....................:.........---.......... <br /> 1 :... y <br /> ............................................t................................I ....... ........................................... <br /> . <br /> Final Inspection by: .. :. - ,----- .. ..�:. ... .................... ' ' ..... Date . . ..Z. 776................... K <br /> .............. <br /> EH 13 2!t 1-66 He . 5M y JOAOUIN LOCAL HEADISTRICT 6/7h 3M <br /> /Vefe. ' 4111 Aous o c' �,FTe .2 t>r104. A10 <br /> t 1 <br /> SE 0ar r+�r,�uf Cs f.✓!� �•/� <br />