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FOR OFFICE USE:as APPLICATION FOR SANITATION PERMIT <br /> sol- <br /> -�-----~ Permit No. ------�`--� <br /> (Complete in Triplicate) <br /> ---------=------ ------ <br /> Date IssuedO <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 7.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 Pynty rdin nce 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI -----...-----CENSUS T _.. <br /> ----- --C,-�--p-------- <br /> Owner's <br /> ---- -- <br /> Owner's Name --- ---- --- --- --- - --- - hone __ _ l 4 ------ <br /> Addressk-- city ----------------------------------••- <br /> Contractor's Name _________. :__ _ _.; __ ` ------------------Lice se #/ Phones -- 1 -7 <br /> Installation will serve: Residence partmentHouse❑ Commerci 177 Trailer Court -,E] / <br /> �.i—' � I <br /> Motel E]Ofh .r -----------------•------------------- -- �. <br /> Number of living units:--- Number�f,bedrooms __ Gar ge\ 'ri oder ��3'./`_ Liiii; <br /> Size _ _`x�yv--------_--. <br /> %-------------- ;., t.. Private <br /> Water Supply: Public System and name ________ _______.__._____.___ __ _ ____ _ ___ ______ _� _ __-___ ❑ <br /> a �----- � •, �, <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑k Peat Sandy Loam Clay Loam ❑ <br /> I <br /> Hardpan Addbe Fill Mbteria{ <br /> X <br /> ip ❑ ❑ �- ------------ If-yes;,type ---------------------------- <br /> (Plot <br /> ----------- -(Plot plan, showing size of lot, location of system in relation to <ells, buil ngs, etc. must�be placed on reverse side.) <br /> NEW;INSTALLATION: {No septic tank or seepage pit permitted if pu`k4licAawer,is available within 200 feet,) <br /> PACKAGE TREATMENT [ 3 SEPTIC TANK�1�14 Size_ ___-_---_-_ ___-_____.__ Liquid Depth __________________________ <br /> Capacity ------------------ Type - ----------- y_ Material--_--- No. Compartments ---------------------- <br /> Distance to nearest: Well -- ---------------------------------Food tion --------------rt_------ Prop. Line -------------•........ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Lengthlof each line.------\-----------.------ Total f Length -_--------.------- <br /> i_Deth .Finer Material ___-_ <br /> 'D' Box ..---------- Type Filter Material -------------------- p -----••--------•-----------------...... . <br /> Distance oto nepfesfiWell __ "'Foursddtion ________________________ property Line -_-_-_----------_._._-_ <br /> SEEPAGE PIT { ] Depth ---i --------_-_ Diameter ________________ Number ------ ----------- _ hock filled Yes ❑ NoWater i❑ <br /> Table Depth -----:----- ( --------------------Rock Size ------------- <br /> Distance <br /> o nearest: Well --- --- ---------Foundation ---------------- Prop. Line --_------------------ <br /> I 4 <br /> REPAIR/ADDITION(Prev. Sanitation Permit c# --------------_------------------- <br /> #I <br /> i Date .---------------�----------------- <br /> Septic <br /> ----------------Se tic Tank (Specify Re uirements) I---- <br /> ----------- _Disposal Field {Specify Requirments),J� -- -- ----- 1 <br /> r <br /> ---- ------ <br /> ilr I t <br /> --- - ----------------------- --- ------------------------ ---------- <br /> -----------------------------------------------------S. i_____-_.._______ ........__t___________________------------------------------_ ---•_ __ <br /> __________________________.._._______.____-_._--._.--___ <br /> (Draw existing and,required..additlon 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, andkRules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: 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 -_. ----------- rO.wner <br /> BY --------------- <br /> ------------- Title �� <br /> -- -- ---------------- <br /> oth an owner) <br /> L�PA�F.POTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- - ------ ------------------------------------------ ------ DATE ...A--6---��------------------ <br /> BUILDING PERMIT ISSUED --------- --- - ----- - ------ -DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ---------- - -------------------------------------------------------------------------------•---------------- <br /> ---------------------------------------------- - - - -- ----- -- -- ------------------------------------------------------------------------------------------------------- ---------------- <br /> ---------------------------------------------------- - ---- - ------------------------------------------------------- ----------------------- --------------------- <br /> Final <br /> -------------------Final Inspection by: ----------------- -- -- ----- - . --------------------------------------------------------------Date --- <br /> J <br /> -J A UIN LOCAL HEALTH DISTRICT �� <br /> E. H. :9 1-'b8 Rev. 5M <br />