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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ...................... Permit No. ...: - <br /> (Complete in Triplicate? """" <br /> H- <br />......................................................... This Permit Expires 1 Year From Dale Issued <br /> Date Issued .-.7 � ` <br /> Application is hereby made to the San Joaquin Local Health District for a perrnit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> �.�....__..�.....----•.. <br /> ........ ........CENSUS TRACT ...........JOB ADDRESS/LOCATION ._.:.:.. ...... <br /> ......,.. <br /> Owner's Name ........_.. '..........:.......................•............................. Phone ..C,��.�>.. (��_....-- <br /> Address ............. �-`7t�3--------.R/.0 '..� ......- ----........ City ..� ------ ...............:........................ <br /> . s <br /> Contractor's Name ....... -A,, FU4L :.............•_......-,... .....L'icense # J .. Phone <br /> Installation will serve: Residence W Apartment House 0 Commercial OTralier Court 0 <br /> Motel ❑ Other .....----"------- -----•......-----•-•••--•- <br /> Number of living units:----I------ Number of bedrooms .11------- Grinder ............ lot Size 4:apz ................. <br /> Water Supply: Public System and name -.........................:.._._.......... -•-•---•-----•------------- --- Private El <br /> Character of soif Ito a depth of 3 feet: Sand[:] ., .Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay oam <br /> H dean ❑i �, Adobe''[] 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 INSTALLS TION: (No septic tank or seepage pit permitted if .public. sewer is available within 200 eet,} <br /> PACKAGE TREATMENT SEPTIC TANK T Liquid De th _ <br /> Capacity 1. Type Material---------------------- No. Compartments <br /> f Foundation <br /> t Distance to nearest: Weil ..__. 4........................ �.¢..� ._ Prop. Line .............. <br /> LEACHING LINE [ i No. of Lines _.._ -............... Length of each line...f�!'_�.__.--------- Total length ............................ �} <br /> ' r <br /> 'D' Box ....1...-.- Type Filter Material .,yob K :Depth Filter -Material ..._..A�0j'//.................. ' <br /> 1 , <br /> I Distance to nearest: Well..... Foundation ../672........... Property Line <br /> SEEPAGE PIT [ j Depth _J.2............. Diameter Number ..__ .................. Rock Filled Yes ® No ❑ <br /> Water Table Depth ....................-...........................Rock Size ................................ <br /> 7-vv r* Z-3 rf� Distance to nearest- Well -----------------------------------,....Foundation .... Prop. Line <br /> REPAIR/ADl7lT ON(Prev. Sanitation Permlt# -------------------------------------- ----- pate .............._................... <br /> ) <br /> SepticTank (Specify Requirements) ................•------..__•..-•--•-..._...-•---...-•----•----•............................--•................ .._..._ ------ ............ <br /> Disposal FieIld (Specify Requirements) <br /> .............................. <br /> ..............••---..._....._..._...----------------------------------------------------- <br /> ..... ......................_.................................... ............................. <br /> .......................J......----------------------- •------------..... ---­----------- ................_r'....::....................... ......._......._........._... <br /> (Draw:existing and required addition-on reverse side) R <br /> I hereby certify that 1 have prepared this 'application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, an1d-Rti1dTs-'arld-Regulations of the San Joaquin Local Health District. HoArle owner or licen- <br /> sed agents signature certifies the following: :_, <br /> "I certify that in the performance of the work for which ihis'perrd Is` ssued, I shall not employ any pars n in such manner <br /> as to become subject o Workman's-Compensation laws of CoilifornIa. ' <br /> ,�. -�.�. �_. x. <br /> �..�.... ...._i0wner,/ <br /> Signed ..-----=--�i. ...... .. .... .. .---•--••- <br /> ----•...,=.. Title _ <br /> (If other than owner) ,�" <br /> FOR DEPARTMENT USI: ONLY <br /> APPLICATION ACCEPTED i3Y... --- .......... ---•-••-•--•--•••- <br /> DATE ....__!;l:_--- ..` ................ <br /> BUILDING PERMIT ISSUED ...._..._... ........................................................DATE .......................................... <br /> ; <br /> -- ----------- -- <br /> p.DITIONAL COMMENTSA ... __ -- ------••------------- -•--••--••-----.------.-....----------------------.--_.- ---- <br /> ......................................................... .......................... <br /> Final Inspection by. .. . ....Y. .......�.............. . .................... <br /> ............................ ....... .Date ... :_! _.. ..................... <br /> i SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> r <br /> E. H.1.3 241-'68 Rev. SM -�-� `i . `' 7172 3 M <br />