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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 'I Permit No. .. --. �16' <br /> (Complete In Triplicate) <br /> I Date issued ..�-�S"".-7' . <br /> This Permit Expires 1 Year From Date,Issued <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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS LOCATIO .��---_-- w t�- -`._..._... ......... <br /> / ---- <br /> c�,,� CENSUS TRACT' <br /> Owner's Nam�e ------------- ----- ---"..._..... Phone .........-....-,....- ..-..._...__ <br /> Address ..- ...2i..T .5.... •• --- --- .. ......... City . , ....................................................... <br /> Ea. p <br /> Contractor's Name .......... -.. ....... ...... ....... ..... ._.. License # Phone _..._.._._........ ........... <br /> Installation will serve: ' Residence Apartment House Commercial ❑Trailer Court <br />; <br /> Motel (]Other............................................. <br /> Number of living units:.-.-./.L' -. Number of bedrooms yCarboge Grinder ............ Lot Size <br />` Water Supply: Public System and name ............................•.............. ...........- .............-..-.........................Private ❑ <br /> Character of soil to a depth l,of 3 feet: Sand D Silt E3__ Clay ❑ ` Peat❑ Sandy Loam 0,Clay loam ❑ <br /> h Hardpan [] Adobe❑ F!N 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 [ I SEPTIC TANK[ ] Size................................•------------------ Liquid Depth ................ <br />` Capacity Type Material- -------------- No. Compartments <br /> Distance to nearest: Well ------------------------------------Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ j No' of Lines _.-----.-- --- ------ Length of each -line-------_-------------_-- Total Length ............................� <br /> ._bDepth .Filter .Materia! ......-.... <br /> .D'°Box ------"-- . Type filter Material ................ ..........-_..................... <br /> Dist --' ....... Foundation ----_---------- ------ Property Line .......................� <br /> Lance to nearest: Well _.....--_.---._. <br /> SEEPAGE PIT C ) Depth Diameter ................ Number .......--- ........._...._ Rock Filled Yes ❑ No i❑ <br /> Water ToOe Depth _.-_---•---•----------------- _---------•-•--Rock Sde ------------------.._... ....... <br /> Distance to nearest: Weil _:..-•............................... Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION IPrev. Sanitation Permit# -•:-:--:...".......................... <br /> ------------- ..... Date _.__. ........--_.__I <br /> -Septic Tank (Specify Requirements) ...:. ........ . -- -. <br /> ....-.......--. _ ... __i................................ <br /> --. <br /> Disposal Field ISpecify Requirements) --�Ct?- --N _... ... -...--.... .................. <br /> I� - <br /> r <br />' - .--- J ----...--.."-----------------------•----- ------••-------- <br /> �I .._.. <br /> ---------------------------------------------- = ..............................................- ............-.......1............ <br /> ... <br /> ('Draw existing and required addition on reverse side) <br /> I 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 Son Joaquin local Health;District. Horne owner or Ilcen- <br />'I sed agents signature certifies the following: <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 /> ,s <br /> Signed ---"--------•------------•---- ------------- ------------ Owner <br /> BY ... -------- ---------------=---"-'- - -- Title '?:........................ <br /> (If other than owner) <br /> li <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -` ----' . . . . ------------------------ ------- ---------------------- .......... DATE <br /> BUILDINGPERMIT ISSUED -`7............. -----------------_----------L-----------___--•------.-----------------------------DATE ----- .....----"--' <br /> ADDITIONAL COMMENTS ------------- ------------------------- <br /> - <br /> ------------------------ <br /> ••-- "---- ;°. 11... ............ _..-------..............................................................................Final Inspection by: .- - <br /> EH13 21s 1-613 v. . -. . ... --•---'......................................................_..._....._....Date -t..--- ...-'. <br /> 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> u <br /> ;I <br /> C1r ` <br />