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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ................ ........ _._...I. <br /> ... . ...... <br /> Permit No. .. �." <br /> •--•-- (Complete In Triplicate} <br /> .................... -4 ._....- ..__...... <br /> This 3 Year from Date Issued Date Issued .. ..:..:......... <br /> -•..................................................... <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 ith County Ordinance No. 549 and existing Rules and Regulations: <br /> q ?._. _. ,1 -... ..CENSUS TRACT ....................:..... <br /> JOB ADDRESS/LOCATION . ...__a .. ... • ..-.. ...J <br /> Owner's Nome f� moi! •''._.11=ut.�f wo .............��...........-....Phone .-........... <br /> ......... <br /> Address . -NAZI. !/ City ...._ _ t.. -------- --------------------- <br /> Contractor's Name ------------------------ I ------... ......................._'-License # ---------...------------ Phone ..---._..._-,-_---•---•----- '. <br /> Installation will serve: Residence❑Apartment House 0 Commercial❑Trailer Court ^' <br /> IMotel ❑Other __------ •- ..... -------- <br /> Number of living units---------- __. Number of bedrooms .. _Garbage Grinder -___-----___ Lot Size <br /> I <br /> .......-• --------------- -------------------•••----..Private,, , <br /> Water Supply. Public System and name --------------------------------•---•----•----• <br /> Pp Y� Y i .. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt El Cloy ❑ Peat ElSandy Loam fl Clay Loam <br /> Hardpan❑} Adobe (] Fill Material ............ if yes,type y............. ............ i <br /> (Plot plan, showing size of lot, lo)6ion of system In relation to wells, buildings, etc. must be placed on reverse side.) t <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if .public sewer is available within 200 feet,} <br /> ,u <br />_ • <br /> +� --•---•--------- ----...------._...--,-• <br /> PACKAGE TREATMENT SEPTIC TANK Size <br /> r aCapacity -----�I--... Type - Materi ... ..... No. ompartments ----- ... .. <br /> . <br /> Distance I nearest: Well --------- --.- •--• ---•...Foundation --- =- - - -- ----- Prop. Line......... -_ ---- <br /> LEACHING LINE K No. of Lin ._.-.---- Length of each lint �� _.�__... Tota! Length _.. . -•.__ <br /> D' Box . .-.. Type Filter Mated Depth Filter Material ..---•,� ( ' •••;y <br /> Distance to nearest: Well _--- ---- -- ....... Foundation ...,4140..__ Property Line ..� <br /> SEEPAGE PIT ) Depth .J................. Diameter _-- Rock Filled Yes No <br /> Number ......................... ❑ 0 <br /> Water Table Depth ------• ---------- .............._...Rock Size ------_------------............ <br /> .. <br /> Distance to nearest: Well -----•------------ .....................Foundation......_..-••---•..._. Prop. Line ............ <br /> ,.---------•� <br /> 1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------- ---------------------------------- <br /> Date <br /> Septic Tank (Specify Requirements) •.................•--• ......... ................................................................1................ <br /> ..........,. <br /> Disposal Field (Specify Requirements) ---•-•------------------- -•-•-----_------------------.....................----------.----------- <br /> --------------------------------------------------- -----• ---------------------------------------------------•-------------------....­-----------------*------------------------------------- ' <br /> ------------------•-------------------- -------- ---------------------------------•-------- - <br /> -----• <br /> : . <br />` .I (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 Son Joaquin <br /> County Ordinances, State Laws, anti Rules and Regulations of the San Joaquin Local Health District. Horne owner or Ilcen- <br /> sed agents signature certifies the following: <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 bec su/b'ect to Work an's omn ensation laws of California." <br /> Signed ._.�---v`- ----- �4�� Owner <br /> -----------------------------------_.- Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY t <br /> APPLICATION ACCEPTED BY ------1j 1j7TX..-- - DATE - 7 .-.. <br /> BUILDINGPERMIT ISSUED ----------- -----------•--•------•------------------------------------------ - •---------------.DATE ------- ---------- ---• ------ <br /> ADDITIONALCOMMENTS -----------I....... . . ..... ----------- ------------• ----------------._............._....................... <br /> ' ---•...... ...................................... .. . ............ <br /> ----------•---..-..._.Date ..... <br /> _ .. ---• <br /> Final Inspection b <br /> k EH 13 24 1-61 R v• 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />