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FOR OFFICE USE: A <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------ - - ------•-------------- ._��_--��_,�' <br /> (Complete in Triplicate) Permit No. <br /> ------_--------------------.---------------.--------_.___ This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to t e Son 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 __. /�- ' ___ ( -- -Q-I ______________._________CENSUS TRACT __5� 0_--.__ <br /> Owner's Name '5PRI mc=-- cl��-----cQ_ &-T­� ------- LV _-Phone ------------- ---------------------- <br /> Address __d�1�_�-T. d-'t--Ai_tf_A_?N --------------- Ci So-j--� -- -- <br /> Contractor's Name --------------------------------------------------------License # 7�g576_- Phone ---------------•-----•-••----- <br /> Installation will serve: Residence ❑ Aparfinent=.Housef-] Commercial ❑Trailer Court �,❑ <br /> Motel-0OtherrrF0-N_,_40[,.F--QQPSF_ RE.sT-R�oM. , <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size __ Cl - ------------- <br /> Water Supply: Public System and name --------------- ------ ----------•--------------- •--------------------•---------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑AI <br /> - - <br /> Hardpan E] Adobe E] -Fill 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 seeps it permitted if public sewer is available within 200 feet,) / C � I <br /> PACAGE TREATMENT [ ] SEPTIC TANK'[7" Size--__,Z---XQ- <br /> � _x_�J-------- Liquid Depth -------7 .--- -_ . <br /> Capacity -12-4:?-C---- Type PRS } Material--CONC _ <br /> _ . <br /> -T p No. Compartments - <br /> _ <br /> ante to nearest: Well ___ __1�,Q_____`` _------Foundation 1P-__-r --- Prop. Line -----5 <br /> • � '-- ----- ----------- <br /> LEACHING LINE No. of Lines --- --- Length of each line----- Total Length --__-. �___t-________ <br /> - ------- --- DD ----- <br /> 'D' Box Type Filter Material.AP j(�f __-_Depth Fier Material _____19-...... ....... .............. <br /> Distance to nearest: Well -,---------------------- foundation _+___ .:___.__________ Property Line _.________________-_____ <br /> SEEPAGE PIT [ ] ' Depth ___ --------------- Diameter _______________ - Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> I Water Table. Depth <br /> ---------------------------------------Rock Size -------------------------------- <br /> ` Distance to nearest: Well ___________________________ ___ _ ______Foundation <br /> - • - -------------------- Prop. Line '--`------------•----• <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------.-----------_-___-___----_) <br /> Septic Tank (Specify Requirements) --------------------------- z r ;= r f-----------------------•---- <br /> -------- = . G ------4i n/OF--------�(--------Wi_.b -------- <br /> Disposal Field (Specify Requirements) _ __`_;:i� <br /> ------------- ------------------------------------------------------------------------------------------=`------------- ---------------------------------------------- ------------------------ . <br /> ------------------------------------- -------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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. Home owner or licen- <br /> sed agents signature certifies the following: _ �1 <br /> "I certify that in the performance of the work for which this permit is issued, Is shall not employ any person in such manner <br /> as to bet?qn a?subject o Worl man Com ensation laws of California. ' <br /> Signed __1!l ✓� / a k J <br /> ---- - --- Owner <br /> BY � / ---------- Title ------------------------------- <br /> (If other than owner) <br /> p FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY T] t 1 �'` =` = - }------------- ti = `-------. DATE ------9 <br /> BUILDINGPERMIT ISSUED ------------- - -------------------------------- ---- -------------------------- --------- - 1--------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -_ - - ---- -------------- ----- ------------------------------------------------------------------------- <br /> ------------ --•------------ ............................. <br /> -------------------------------- ----- ------ - -------- <br /> ------------------------------------ <br /> - --- <br /> Final Inspecti �_-- <br /> e- --- ------------------------------------Dat --- - ------------ - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT" <br /> E. H. 9 1-'68 Rev. 5M <br />