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a7 �FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> J ' �' (Complete in Triplicate) Permit No. r—.... <br />................._..., ................. <br /> V <br /> •................. This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San JoaquinLocal Health'Districttfor.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 /> JOB iADDRESS/LOCATION ... .:.��S_...5�,�._•... 9-�tx ,tp <br /> / � ............................CENSUS TRACT <br /> Owner's Name ................ Y1[.X.. <br /> L :-- ------•�. ..._ . ... .........r-----...-...... .. •............._ .Phone <br /> Address _. �� !� City <br /> Contractor's Name ....................... _ _ + license #s?��f ._ Phone _._..........-•-.-- <br /> _ _ _ - ..... ....... . ,..___ _"S ... ........ <br /> Installation will serve: ~ Residence)9 Apartment blouse 0 Commercial ❑Trailer Court 0 <br /> Motel ❑Other ..................................... •.... -- -_ _ <br /> Number of living units:._.__ _-_--- Number of_bedrooms., : <br /> _ge Grinder ............ Lot Size ........ ........... <br /> - W. .........•............. <br /> Water Supply: Public System and name ........................... __...Private ❑ <br /> Character of soil to a depth of 3 feet: - Sand❑ „ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam D <br /> - Hardpan ❑ AdoWZ Fill Material ............ If yes,type ..................... <br /> -----• <br /> (Plot plan, showing size of lot, location ofsystem 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,j <br /> , <br /> PACKAGE TREATMENT [ ] SEPTIC TANK-{—]a ,, ry 1 Size................ <br /> . Liquid Depth y r: <br /> a <br /> tj <br /> dty <br /> Capa <br /> .................... Material.................. No. Compartments <br /> Distance to ne ra est: Well ._Foundation .. Prop. Line <br /> f <br /> LEACHING LINE [ ] •,JNo hof Lines ....................... Length of each line---.-_-- ---....... Total Length <br /> .. 'D' Box ............ Type Filter Material .......... Filter Material ' <br /> -----•---...... <br /> . <br /> Distance to nearest: Well ........:............... Foundation .. .. Property Line ........... 4 <br /> SEEPAGE PIT [ ) :, t` Depth .................... Diameter .....__. ....... Number ..-•--------­------------ Rock Filled Yes ❑ No <br /> Water Table Depth -....... : .....--•-• Rock Size <br /> • <br /> ;.Distance to nearest: Well --••----•-•-------• ..................Foundation ... ......... Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation'Permit# _ Date <br /> Septic Tank (Specify.Re uirements <br /> q ! ..... - ........................... .........-.-----•......•---- <br /> Disposal Field (Specify Requirements) --- „_.-••....... <br /> a, <br /> ..............•-----------• <br /> Draw existing and required addition on reverse .............................side) , <br /> I hereby certify that I have prepared this 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 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 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.,, <br /> Signed ........ .� Owner I <br /> ----•- <br /> B ..... _ !.._... f <br /> By ---- .. Title .. ...._._.. ` <br /> (If other n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.... ... . .. ............ <br /> BUILDING PERMIT ISSUED <br /> ............................. DATE ....rte sx�.�.. . '7_..• ..... <br /> .... .... .....••. = <br /> ............DATE ADDITIONAL COMMENTS "'-'••--"-"""'""""""""' '•' <br /> ........................................................ ---------------•••. <br /> ................ .............. ------- <br /> \ --- •-•--••...•... ................................•-•---------..._............... <br /> �L...J........... .. ...... ....... <br /> II .. ... ...................................................................................................•-.._........ <br /> Final Inspection by: .... <br /> Date <br /> ... ... .............................. .... <br /> -Y - <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> 1 <br /> E. H. 24 -'G8 Rev. SM <br /> L3 kF � - • <br /> _ <br />