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FOR OFFICE USE:, <br /> A fuAPPLICATION FOR SANITATION PERMIT <br /> '. �� ................ (Compleb In Trlp"catel Permit No ..................... <br /> :.......... ...................: <br /> ........ This Permit Expires i Year From Date Issued Date Issued.....5�.. .�� <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 c plianFe with County Ordinance No. 549 and existing Rules and Regulotionss <br /> 1S� •3 C�� f'C'7� ��(�T- <br /> (Vl <br /> JOS ADDRESS/LOCATION ........_..... ..._ ri............ ....!.FM! NAC.................. .....CENSUS TRACT ....................... <br /> Owner's Name ............I.. .7._3. :...... �Z f�oj 7 ,M,AV 7 /.. ._.Phone ...__ .Z . <br /> Address :............ .....------...........---...........................................city N.j " .......................................... <br /> IJ ... <br /> 4ic�srtss ...����✓_ Phone ......................... . <br /> _........ _._ <br /> Installation will s e: kssidence Q Apartment House Commercial QTrailer Court Q <br /> Motel Q Other..----•-......_ <br /> Number of living units 2 b� <br /> - g -._._:-.:_ Number of-bedrooms /......_Gar Grinder ............ lot Size ............................................Ll <br /> Water Supply: Public System and name .__�L`r�----- ---------------- 0 - -------------------------- ............Private Q ; <br /> Character of soil to 6depth-bf1fert: Sand SiltQ Clay Q jPeat QSandy loam Q gay loam Q "11 <br /> Hardpan Q Adore Q Flit M6terlal ............if yes,type--------------- -------- -- <br /> (Plot plan, showing size of lot, Iration of_systeaa-in--Tofoftn to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepagcr pit permitted If publk sewer-is available within 200 feet,( <br /> PACKAGE TREATiiI~~EN ( ]r�SEPJW{ I Size................................................ Liquid Depth ........._ ...... <br /> pT l , opacity .................... <br /> Type ................ Material ......-•---....... No. Compartments .................... <br /> l Ga Distance to nearest.rWell ....................................Foundati ............ Prop. line .... ........ <br /> LEACHING LINE [ No. of Lines .......l ._..-_.---_ Length of each live....... Total Total Le .....1A'.......... ... <br /> 'D' Bax ......1.... Type Filter Materi 1 ........".Z!.1--.De FilterMaatterial ,....��/....�....._.. <br /> Distance to nearest: Well .....,2�� f".... Foundation _..,�.�..�.. '.. Property Line .....`-'.........( <br /> SEEPAGE PIT [ l Depth -------------_---- Dlttmeter ................ Number ............................ Rack Filled Yes Q No Q <br /> WaterTable Depth ................................................Rock Size ...........4.................... <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ................................... <br /> Septic Tank (Specify Requirements) .......... ..............-- ....---....... .... . ........ .. ..l....:. ----------- <br /> --------.-.. <br /> Disposal Field (Specify Requirements) ......--•----•---------•............................................................................................................. <br /> --•---------------------------------------- ------------------------------------------ ...........................................................................................................I------- <br /> •----•------------- ---------------------- .........................................................._........................................F................................................... <br /> (Draw existing and required addition on reverse side! <br /> 1 hereby certify that I have prepared this application at►d_that the we* wIN be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San .Joaquin Local Heallh-District. Nonce owner or New <br /> sed agents signature certifies the following: <br /> "I certify that in the performance pf the work for which this permit is Issued, i shall not employ any person In such manner <br /> Of t0 beco sY (@� a W k 1 .Ca 'satian Mws <br /> �__ of California.California."Signed -- • - ?/1•- Owner <br /> By ------------------------- -_--------------- --•--•-----------•--------•----- title <br /> (If other than owner) <br /> R DEPARTME . :USE ONLY <br /> APPLICATION ACCEPTED BY ���---- - - •=--------�-------------------------- ----------------•--........-............. DATE --..�r.�.•.._-�.�--.2.�.....: <br /> BUILDING PERMIT ISSUED ... ............... <br /> - DATE .... <br /> ADDITIONALCOMMENTS .,.. -------•................................................................. ....------...._........._ ......................... <br /> ---------I...­---------------- ---------------- ------------------•---- ..........._........ .--.-_,._......----................... ... ............................... <br /> ....................................----------....................... ..........................•...... <br /> -- ------ ---• . ..................................__..-....... ......---............... <br /> .. <br /> Final Inspection by: __... ----- -- .....Date . `I ....'- <br /> EH 13 21{ 1-613 Rev, 5mSAN JO UIN LOCAL HEALTH DISTRICT 8/711 3M <br />