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k FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Z�i <br /> a....................................... ............ . Permit No `'_ <br /> (Complete in Triplicate) <br /> ....._....f.....................:.................... This Permit Expires I Year From Date Issued Date issued. - -7>_�� <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/LOCATION <br /> -,._..>_...SIYX,�,,� ..-../A/ .............,.. CENSUS TRAGI <br /> Owner's Name / ....... .....................................:...,.....................................Phone ...... <br /> Address ........... ......................... ......... City --- - _X/..:................ <br /> Contractor's Name,:__.l _ �,1 -y�" ,ll�i�C _ ..License # / _ Phone <br /> Installation will serve: ResidenceK Apartment House❑ Commercial ❑Trailer Court a <br />! Motel ❑ Other ........................... . <br /> Number of living units:-...... Number of bedrooms _.,...._Garba- <br /> ge Grinder /YD.. Lot Size .___/ -&Iacr............. <br /> F <br /> Water Supply: Public System and name ---------•------•---•- -•---•------------------------------------•-------------------------------------------Private <br /> i Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ -.Peat[I Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ............ If yes,type -------------•-------------- <br /> f (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 D4 Size_ f <br /> j � ���--.�.�,�.....----•---._.. liquid Depth ..,SY.............. <br /> Capocitylo& > Type MaterialCompartments <br /> Distance to nearest: Well /�1 . p. —&. <br />. ---.'_----••..............Foundation ........----_-- Pro Line —& <br /> - s <br /> LEACHING LINE kj No. of Lines ...../---------------- Length of each line-_-__:I,6le- ..:.__.._> Total Length lCtl................� <br /> 'D' Box / Type Filter MaterialDe p <br /> th Fitter Materia! _ .................................:. 0 <br /> Distance to nearest: Well . _._� ' r... .....,r' r <br /> „� ..... ... Foundation . Property Line _�r�_.°-.___. <br /> SEEPAGE PIT f Depth j' ! F [] <br /> . .--_.._. Diameter - '� •__._ Number ..... .. .............. Rock Filled Yes� No <br /> •-: t Ir , <br /> Water Table Depth ...................... - -(......... <br /> Distance to nearest: Well .,/r7�.................... r <br /> __...Foundation .-./0- ____.__ Prop. Line _->�r>___>._...... <br /> _ ! <br /> � REPAIR/ADDITION(Prey:Sanitation Permit# .......................................... Date _.._..........--•-•-_-•--•---•--..} � :• <br /> Septic: Tank 5 eci Requirements) --.--•-•--•----••-••-----..._...-••----.....--------- =- <br /> Disposal Field (Specify Requirements) ............_>...............................---„__,_----. --- ......-•-•--„_-„--,_,,...... • -----• --- -------•------- <br /> 1 <br /> -_----•-----•-----•-----•------•..----•--•--------------------------•-.•.------•-----.------.-•--••--'---...._._.______....... .............-.................-.............- _;­...-__..__. <br /> ,f - <br /> �- Y <br /> :::.::..............:....................................................... <br /> I (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. Nome owner or licen- <br /> sed agents signature certifies the following: 4-- <br /> "I certify that in the perFormarice 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 /> ------------- <br /> By ................... j >...... Title ....... l�7 . <br /> ',.........._......... . ..................•••--••--••. <br /> eri <br /> (If other the n <br /> - <br /> FOdEPA' RTMENT,,ArSE ONLY <br /> APPLICATION ACCEPTED BY . .... ... ... ... ............. DATE __�� . .._..?.-7c`a......_._ <br /> BUILDING PERMIT ISSUED ..... ......:........ ....... ................................ ..........................:..............DATE ........ -••--•---•----........ ....... <br /> ADDITIONAL COMMENTS ---------- ----•-- .......................................>_».................................. <br /> ...............................................X _ _:_>.._•---..__... _........-_.....__»____._..___..._.._---•--..•--...I._....._......_..._...._....................................... <br /> .......................................... ........................................... <br /> _._____.._....___ ______._._ f <br /> J <br /> Final Inspection by: ......... ... . .. . . . • ....... <br /> -•••-_......__••---••-----..__....---•-•--•-•-•->........._..Date ...� .. . ..`. ......... <br /> SAN JOA IN LOCAL' HEALTH DISTRICT <br />