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FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicatef <br /> . .C�. J1 .�._........ Permit No. ................... <br /> i'Ms Permit Expires t Year From Date Issued Date Issued ._ � . <br /> k <br /> Application is hereby made t the Sah.Joa <br /> • mquin local Health District for a permit to construct and install the work herein <br /> described. This application is made in copliance4ith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .._.. �- <br /> Q .R ............... <br /> TRACE ..... <br /> Owner's Name AQ•Q_ -F ? <br /> Address ..__.. ® 3 ----•- .....--- :• -,•_•-..... Phone ,�. !. . <br /> ? __ '::�~ .... .:. :-.•FCity .. -� <br /> Contractor's Name ............. id ...............�.......... License /�4?.T._.: - -... Phone . ���(J7 ....... <br /> Installation will serve: Resehce, Apartment House C) Commercial[]Trailer Court ] <br /> - t <br /> Mater (]O her,. ............................... <br /> Number of Irvin .� <br /> g units:_..-- _ -•- Number of bedrooms __6.....Garbage Grinder ......... Lot Size,,._.__.. <br /> Water Supply: Public System,and name Private <br /> ---........¢............. ....... .......................................... <br /> Character of soil to a,depth of 3 feetr- Sand - silt ' <br /> Gray•j] beat❑ Sandy Foam ❑ Clay Loam 0 <br /> Hardpan❑ Adobe] Fill_Materlal ...._.......if ,type ........... ....... r <br /> t <br /> yes !.. <br /> (Plot plan, showing size-of lot, location of system In relation1to wells, buildings, etc. must placed ani reverse aide.) <br /> NEW INSTALLATION No septic 1 t ) y ' <br /> p c tank or seepage pit.�ermitted if public sewer Is available within 200 feet;' <br /> PACKAGE TREATMENT [ SEPTI C TANK t t ' <br /> I . <br /> S:ze - ----- --------------•-----....._ Liqu€d Depth ................. <br /> .. Material.__ <br /> -Capacity -...--....TYpe ----- Compartments -- --.......- <br /> ----•---••--- No Compa <br /> Distance. to nearest:Well a .._.... <br /> en <br /> - �_ _~'t.=--...--••�-------.�....Foundat ..---....__. � ..... r n <br /> LEACHING-LINE [ ] r — <br /> I ion -- Pop. Line e ...:..................J <br /> ta jNoaf`Linese cf ech` Iine.• Total Length/............................W <br /> -• -..:. <br /> ► .,� ,, -' D' Box ..---•---•• Type Filter Material '.......---•- i•---Depth .Filter Material .... .... ../.............................. <br /> .Distance to nearest: Well.......... ... Foundation ........................ Property Line <br /> SEEPAGE PIT ( 1 Depth Iltumeter <br /> Number Rack Filled Yes ❑ No �❑ <br /> ....r.� .,P ..... Number <br /> Fable Depth .......................... .. ........_Rock Size <br /> .............. <br /> •............ .••_i <br /> Distance t nearest: Well .............. I ....Foundation Prop. Llne'�f' <br /> • ................. <br /> REPAIR/ADDITION Wrev-Sani ation Permit - <br /> ....-------- ----- DateV...._ f <br /> w <br /> If+ <br /> Septic Tank (Specify Requirements). ! t � <br /> -- - --------1 <br /> Disposal Field (SpeLay Req iu rements] �p I .......... ..•------------- <br /> t` - -----------••-•---. . •• --....... .. I <br /> . _ - ! <br /> - --- ... <br /> ._�.----..----. --- •- <br /> . (Draw existing and required addition on reverse side) <br /> i'heretiy-certify�fhat'!`have prepared`thPa application and lhof the work will-be donei ccordance 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 in the performance of the work for which this permit is issued, l shall not qmploy''any persons In-such manner <br /> as to become subject to Workman's Compensation laws of California." . <br /> Signed <br /> ------------------------------ -- <br /> -------- ••---•• --------- -------------- --------- Owner <br /> B ............... --- ----••-- <br /> L <br /> • ------ ---­------­----------1. Title --- ...------••......--nowner) <br /> Otert <br /> — R DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... <br /> . ............... -------- DATE ... <br /> .... . . . -. <br /> BUILDING PERMIT ISSUED ................................ <br /> ................... ..----_----- ..............DATE - .............................. <br /> ADDITIONAL COMMENTS ....................:...........• <br /> ------------------------------------------------- . j <br /> ----------------•----- <br /> --- ---. - .._-. <br /> ------------ - ----------------------. ---- -. <br /> Final Inspection by: ..---- •. ----- <br /> ------- ..--•-- -- -------- ........-Date �. <br /> { ✓• - <br /> EH 13 2h 1-68 Rev. 5M <br /> SAN JOAQUIN LOCAL HEAL T DISTRICT 8/74 3M <br />