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! FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �7 <br /> 71............................... Permit No. .. ......... <br /> (Complete in Triplicate) <br /> ...............•• This Permit Expires 1 Year From Date Issuer! <br /> Date Issued .. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein X <br /> described, This application is made in tom liance with County Ordinance No. 549 and existing Rules and Regulations: <br /> i <br /> '...!.-r-. ...._... ------------ -- -- CENSUS TRACT ..................... <br /> JOB ADDRESS/LOCATION .. -_-- -- � `"A""�"! <br /> Owner's Name ........... ... v[ 4.� - ........ .. ha -.__.. _ ........ <br /> _ f ne �7y <br /> Address 7 �- -------- ------------------- City :._...:._....._...... <br /> do <br /> Contractor's Name .. .d (... Y -'vL/y------ License #o?S `f Phonep� .--- <br /> Installation will serve: Residence's Apartment House❑ Commercial ❑Trailer Court C <br /> Motel ❑Other ...... . .......... ...................... <br /> Number of living units: Number of bedrooms Garbage Grinder ...... Lot Size .__�C a�- ---------- <br /> Water Supply: Public System and name ..............................----•-...............---------------------------------------------------- r`' Private <br /> Character of soil to a depth of 3 feet: Sand M Silt❑ Clay ❑ Peat[] Sandy Loom ❑ Clay Loam C] <br /> Hardpan [❑r;� Ad be ❑ Fill Material ............ If yes,type ......................... <br /> (Plot plan;showing size of iot;1locatian of system in relation'to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTAWATION: {No septic tank or-seep ge,pit-permitted-if-public-sewer-is-available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SE;PTICTANK.1 ] Size Mater---------------------­-- - yL'iquicE Depth .__..`.....'}" ......- <br /> ► _ ` r ..._... T e - - ►,-.. 4 ial................._- . No Com artments - <br /> Capacity .. ._ ... Yp 4••-- p <br /> Distan+;e to nearest: Well . -.._ .----------...................Foundation ..... ....._ ,,--„ Prop. Line!,._._..-------........ <br /> LEACHING LINE ( ] o. of j Lines Length of each line .......... -............--- Total Length _...__(. _...-- <br /> D' B-0'X! .. Type Filter Material ....................Depth Filter Material ....------_-_._....-: <br /> Dist nce to nearest: Well _................. ...: Foundation ._--------,_._...-...... Property line _....................... <br /> SEEPAGE PIT Depth- . --------- Diameter ........ ._...Number :.__ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ........ .................... Rock Size ---•-- --- -•-- ----.......- <br /> Distancet to nearest: Well ..-.-.....---..._ `-__1"t--------_Foundation ..... . .... Prop. Line r_........--_.._.._.. <br /> ` ) <br /> REPAIR/ADDITION(Prev.ISanitation Permit# _ -• ----...---- -------. Date .-.. ... ..._-._..,_.-.-------- <br /> Septic <br /> ------ t <br /> Se tic Tank (Specify Re uirementsh..--- �� ....... .. :r., ....,.-.r__ .-_�------------------------- ------...._......._-. <br /> P P Y q r I <br /> Disposal Field (Specify Requirements) ...-.._.____Q ---�- ---- ....... .. ."f------ ------- ....... ...... <br /> - j <br /> ........................... <br /> .......... ` -- -----------------i • .----- �...� <br /> Draw existing-and'regbi.led addition on reverse side) \ 1 <br /> 1 hereby certify that I h ve prepared this application and that the work will be done in actortibnce with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Jeaquin%tocol'Healfh District/Home owner or licen- <br /> sed agents signature certifies the following: �e <br /> "I certify That in the performance of4the work for which this_perm_it,is issued, I shall notsemploy any parson in such manner <br /> os to become subject to Workman's Compensation laws of California.” <br /> Signed .:.. ............ ......•--�---- ------.. .._.. ..-�-•- - ----------------------------- Owner <br /> BY r... (��/�.... .................. ...•• - Title <br /> �... <br /> (Ef oth r t owner) <br /> OR DEPARTMENT USE ONLYy <br /> APPLICATION ACCEPTED BY .. ` . _ c: - --------- I i-. ----- DATE � .% ,1. .. ......-......•...... <br /> BUILDINGPERMIT ISSUED ,-.... --- --------- •-................_,. .....r---..----- •• --•-------....DATE ............ <br /> ADDITIONAL COMMENTS .. ..............� .................� , ---- .„ -(- <br /> -- ...._........_..---- � <br /> .. ..... ;.r'--...---- <br /> r <br /> •----- ------ ._...... :wt---------.---------------- --- •-•---.._....---....-•-------.....--•- ......_...-----....----- <br /> -...._. <br /> -� .J -.f 1 �, _----Date <br /> Final Inspection by: .. s . A .............. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> mm i <br /> ., 7172 3 A <br />