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FC+R OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. ..7.y.. ..... 1 <br /> (Complete in Triplicate) <br />......_................................................ <br /> ............:.... . This Permit Expires 1 Year From Date Issued Date issued . -�1 <br /> Application is hereby made to the San Joaquin Loa! 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: <br /> JOB ADDRESS/LOCATIO 1. 90 ...: .; -r. - 4.................................. ....CENSUS TRACT ..............:.:..-...... <br /> Owners Name . ..... . :.....................Phone. . <br /> 36 -..�/. <br /> Address .................... gre.. ............................. City _ ...---•-----•-••-•....................... <br /> .... . .................License # PhoneContdractor's Name .............. . ./�d/.�...�...�..T <br /> �. .... <br /> Installation will serve: Residence Apartment House C] Commercial OTraller Court 0 <br /> (Motel ❑Other ............................................ <br /> Number of living units:.......-. Number of bedrooms .__??-.....Garbage Grinder ...... Lot.Size ................ <br /> Water Supply: Public System and name ..............................................................................................................Private <br /> Character of soil to a depth of 3 feet: i FSand b ..Silt 0 -Clay+❑ '•-Peat❑ Sandy Loam_-❑"-Clciy-tbam Q- <br /> Hardpan Adobe.V Fill Moteriol ............ If yes,type -- .............. . <br /> {Plot plan, showing size of lot, location of. system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: I j <br /> {No septic tank or seepage pit permittek Itd-if-public.sewer s available within 200 feet,) <br /> .11 <br /> PACKAGE TREATMENT [ ] A• SEPTIC TANK 1: � �S e._ ? ---- ___.X___t......:,_ _r-"'"yLiquid Depth .. ............. <br /> DYdJ t <br /> .„Capacity i�---- :• Type ...................Material__Z -.:.. No. Compartments ....� .....� <br /> _Distance to nearest: WWII"" F-..--� �... ...........Foundation ....1-Q.....-.....-- Prop. Line ...- . .......... i <br /> LEACHING LINENo�of Lines ..... -_-'.._ .-- ength sof each cine---._..: D Total-Lengthy .. . ................. O <br /> {'"" . D'-jBoz;.....--Type F Filter Material ._llE(....Depth FilterMaterial -----I --��.......................... <br /> Distance to nearest: Well ..._.��_.. -.. Foundation _1_02'.l..... Property Line ....5. .7`......... <br /> i .1 ,r i V <br /> SEEPAGE PIT Depth .... . Diameter ..d�t�:..--:- Number 1.: :-....._... Rock Filled Yes No Qr0 <br /> Water Table Depth .................Rock Size .......... ...... <br /> Distance to nearest: Well .......1Q .....J.............Foundation ...../ ..`Y ...'Prop. Line .......�- `......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. . <br /> Septic Tank (Specify Requirements) -...-------•..............••-•-------•---••------...-•-----•---•-•-•--•----•---•-----•---•-•••--......_..._....... <br /> Disposal Field (Specify Requirements) ------ ------ --•--•------------. ....................................................................... <br /> ....... - .......................... <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 Son IJoaquin <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 folio'wing: I <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 <br /> By •.......... ........ ......... �......_ ...... --------------. Title _4 --._.._...--••---•-------•-•------..__....------•----- <br /> {If othe an owner) <br /> L__-_m_—F•OR_DEPARTMENT-USE <br /> ..ONLY ---�-"- <br /> APPLICATION ACCEPTED BY .---------..A..-�'--�--...__-- --------. DATE _...-.. ..... <br /> BUILDING PERMIT ISSUED . ..: '....� ................. ...........................••-•..............•-••••.DATE . .......--•---••--••• -••---•••-- <br /> ADDITIONAL COMMENTS ... ..------ <br /> /'' 'r'x -------- <br /> ---------- <br /> -•- - <br /> ................................................. t.._ . c!ssn�c... ...... -........... <br /> ••--•--•.................................... .. -,..... ... -•----............ ----••....---•-------•--. .......... ...... <br /> Final Inspection by: ...:....... .. -:Date .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E_ }�_ <br /> 13 24 1.'6B Rev_ 5M 7 7+2 3 LK <br />