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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. - _2,Z G._9. <br /> ----------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Lqcal Health District for a permit to construct and install the work herein <br /> described. This application is <br /> made in comp ' n w' County nonce No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION S- [J_6) - --------- -- _. -----Q-------------4.------------CENSUS TRACT -----------_--.-_. ---_ - <br /> Owner's Name Pitor <br /> a j A I i L 4 <br /> �e�.�"f- CS,- - -- - -- ----- -- ---- --- --- - - - ".�- <br /> Address --------------- /. 4 -----±--� - ------------------ `.__. city 5---- ---C�"-19- V------ <br /> ------- -•---------. <br /> Contractor's Nam ------ - ---------A / -------- ---- --------------S--------- -------.License #106S1 I ----- Phone 4-i�? 3-1- <br /> will serve: ResidenceXApartment House❑ Commercial :❑Trailer Court ;❑ <br /> `� Motel ❑Other -------------------------------------------- <br /> Number of living units:. _ ---- Number of bedroomst%)---Garbage Grinder 1v-0--- Lot Size _ _-� __A_1__5�-________ <br /> Water Supply: Public System and name -------- <br /> - --------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt'❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe)!�L..Fill Material ------ ----- 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-----------------------------------i----------- Liquid Depth -------------------------- <br /> Capacity <br /> _______________-_____ ___Capacity ---- --------------- Type -------------------- Material---------------------- No. Compartments -------------- ....... <br /> Distance to nearest: Well -------------------i----------------Foundation ------------ Prop. Line -------.-------..-.._ <br /> LEACHING LINE No. of Lines ------_------------_---- Length of each line--- ------------------------ Total Length ---------------............. <br /> 'D' Box __ --------- Type Filter Material ____________________Depth Filter Material ----------------------.------............... <br /> Distance to nt nearest: Well ---_____________________ Foundation ------------------------- Property Line ........................ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size --------------------------------- <br /> Distance <br /> ------------- -- -------------- <br /> Distance to nearest: Well _______________________________________-Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation .Permit# -------..__ ---------------_--------------- Date _________________________________j <br /> Septic Tank (Specify Requirements) -------------- --- ---- ---- -- ------------- - -- -- ------------*------- ----------------- <br /> Disposal Field (Specify Requirements) ---- --------------- --------------------------------- <br /> -------�------------- ------- -- -- - -------------------ZOO--- <br /> U <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 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 i the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to becom s ject to Wor man's am ensati.on laws of California." t <br /> } <br /> Signed --- --- -- - -- --- --- -- ------ ---- --- --------------------- ----•- Owner <br /> B t.------- - _ - Title ----- <br /> (1 other than owner) <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _______ __ _ __ DATE _-.���_, y--------------------- <br /> BUILDING PERMIT ISSUED -------- --- - ------- ------------------------------- ---- - <br /> --- <br /> -----------------------------DATE ---------------------------------------- <br /> - - - - - <br /> ADDITIONALCOMMENTS --------- ---------------------------------------------------------------------------------- ---- ----------------------------------------- <br /> -- ---------------------------------------------- -- --- ---------- - ------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- -------- --- - -- -- -- ------- - -------------------------------------------------------------------------------- ------------ -------------------------- <br /> Final Inspection by: ------ -- --------------------------------------- ------------------------- ------Date ------- - _ -—------- <br /> SA JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br /> t <br />