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r <br /> FOR OFFICE USE: <br /> APPLICATION`'FOR SANITATION PERMIT <br /> �.3... <br /> •--..� - Permit No. ......... <br /> ...... <br /> (Complete in Triplicate) <br /> '........ <br /> ._,� -' Date Issued ...._'......�3. <br /> „ ",;' -.�.-i__-_•---- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joagwn``1:ocal;Health District 'for- a permit to rconstcuct and install the work herein <br /> described, This application is made in compliance with,County Ordinance Nb 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION :.. ..... ���1? /.�! ..........::........`._......CENSUS TRACT .... <br /> ne 'sName O <br />' Address / ...... City <br /> . ......... <br /> r <br /> .....; <br /> Contractor's Name /!� ".........................:.........License # ?; / `,��_.2. Phone f .:�z <br /> Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court <br /> 1/ Motel ❑Other ... ..... .... ....------------.....•-_._.. <br /> Number of livin units:__.. _____._ Number of bedrooms .: G <br /> g l arbage Grinder .._ .�;�. Lot Size �,� .., ./.,. ....... <br /> Water Supply: Public System and name __-(� �fT;Cf,1.G{l?L., ❑ <br /> .._. � ..� _.�.............•--�--....:......,..........Private <br /> Character of soil to a depth of 3 f et Sand❑ Silt❑ Clay ❑ Peat Sandy Loam ❑ . Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ------------- If,yes,type ... ......:......:......:... <br /> (Plot;plan, showing size of lot, location cif. system in.relation to wells, buildings, etc. must be placed on' reverse side.{ <br /> NEW INSTALLATION: (No septic tank or,seepoge pit permitted if public sewer as available within 200 feet,) <br /> PACKAGE-TREATMENT [ ] SEPTICTANK� Size`. ..,/� i!`F _...._:.___. -Liquid Depth' .�/1. .............4'�� <br /> -- Y, <br /> 'Capacity 12_C� Type%` ._ Material.de91,6,... No. Compartments ... ....._ J <br /> f �_ <br /> Distance to nearest. Well __._Foundation ----- Prop. Line ..-90.1... S <br /> LEACHING LINE [ 6No. of Cines _.____ _-._______ Length of each line---- Total. Length ,�_�L�.�:-_--.---. <br /> Z r ' t� <br /> 'D' Box _ _�_ _ Type Filter Material ,ll�,L�,�-kAepth Filter Material /1��....._.. .._................ ..� <br /> Distanc to­_neareit: Well _....."-"�___.-... Foundation .. ��.............. Property Line. --;,,.................. 1, <br /> SEEPAGE PIT Depth __ ._ .. Diameter Number ...___ i . <br /> `� <br /> .-•-. - ---------.------ Rack:Filled` Yes No <br /> Q <br /> 9 <br /> Water Table Depth ......Z�5 .................. J�........Rock Size _/� ✓�.... .__.. <br /> Distaece tains"arm: Well`--------------------- 1=oun7ation ....__. "Prop .Line --• ............... <br /> REPAIR/ADDITION(Prev. Sari:tat on-Permit# ....................:......... Date --------......_.._....-----•--.- ); 9' <br /> V <br /> Septic Tank (Specify Regbirerrtents) .... .............. ......... .............................................._.................................... ----- -•- <br /> Disposal Field (Specify Requirements) :........ ------_--=-------- ...... .............. -------------:....................; ...._......--- .... <br /> - ----- --------------------- ........................ <br /> -------------- - ---- -------------- --------------------------•-••--••--•----•----•---•------------------------------------------------------------------- <br /> ... <br /> l -.: ...••---...• ---- ....................................... ........... . <br /> (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 /> l County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health Dlstelt-t. 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, I shall not employ any person in such manner <br /> ' as to become subject to Workman's Compensatlon laws-of-California."-�°--_ - <br /> Signed ..._._..`':.._� .�. �_._..--- ew <br /> Owner <br /> : <br /> . <br /> By .............:............ ... �. T,tle - �. <br /> than owner) <br /> FOR DEPARTMENT USE-ONLY <br /> APPLICATION ACCEPTED_ BY .. .:. - A :... DATE <br /> BUILDING PERMIT ISSUED ............................................. " ......DATE _ ._..............._....._. <br /> t ADDITIONAL COMMENTS ...................... " ' ..... ..............�.:.._. <br /> .........................•-..........---•--•......--••-•••-.......- .... <br /> ..-•..........:.... .. .........•._.... ---------- ---•--------•-•-•.....,...._._.._.....---------•----------------••--•••-•......e. _•---...---_..._ <br /> ---------------------------------- <br /> Final Inspection by: .. ---- -- -- Date .._ . -------•-- ......••• <br /> : -� �-- <br /> f SAN JOAQ LOCAL HEALTH DISTRICT <br />