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/ F�O/i OFFICE USE: <br /> ',4' l APPLICATION FOR SANITATION PERMIT <br /> ` 6=X F-,�`-----------------/0-�, --- Permit No. . <br /> 3:2 , (Complete in Triplicate) <br /> - = - '7 <br /> Date Issued <br /> _ <br /> ------- -_---------------------------------------_---- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made . e San Joaquin Local Health District for a permit to construct and install the work herein <br /> described, This applicat' ,is ma in compliance with County Ordinance No. 5549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TION '"- !1- ------ -- ------CENSUS TRACT ---------------------_---- <br /> d <br /> ti � <br /> Owners Name 1 - 1 ► -------- - -- -� -- Phone <br /> EM <br /> Address ------ ---- -------- l/� —I ------�_-�---1- --1-zq- �---------------- City /c� - -----------------------------------------..----- <br /> Contractor's Name _--! 7'> —_e, 6P__1--- ------------- ------License # 1-- -Phone���5�__ <br /> R -- l P ❑ ❑ <br /> Installation will serve: Residence artment House Commercial: Trailer Court ❑ <br /> IrrMotel ❑ Other" _-.----------------------- -------- <br /> Number of living units:------- Number of bedroomstiJ------Garbage Grinde - Lot Size � ---- <br /> Water <br /> --------- <br /> - <br /> WaterSupply: Public System and name __ -�___________________ __Private~ <br /> Character of soil to a depth of 3 feet: SanEd'❑ Silt❑ Clay ❑ Peat❑ �Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ill 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-.seepage it permitted if public sewer is available within 200 feet��e <br /> PACKAGE TREATMENT [ ] SEPTIC TANK1[4 " • -.. -----�--r- q P <br /> ize-------- ---- �n --------- Liquid Depth -- <br /> ------ <br /> Capacityqq��-__,__ Type ��_ __ _�'_ Mafierial______ _______ No. Compartments ______.�___.....___.. <br /> s <br /> -f -- , YP ,, f <br /> Distance to nearest: Well ___ --------------------------Foundation -_l�__ _________ Prop. Line -__________..__.__ <br /> ___ Length of each line.__ t_I'S---- Total 'Length /,r-LEACHING LINE [ Na:° of Lines ______ � _,-_-____- ; <br /> € ----------------- <br /> ------------------------------------ <br /> 'D' Box �{ex___ Type Filter Material _�/ ____Depth Filter Material _ ----------------------------•.•--- <br /> `-Distance to nearest: Well -__._J�____________ Foundation __,1p_ __________ Property Line.-- --•--- ,) <br /> SEEPAGE PIT Depth � .......... Diameter�3-`�-__ Number .-_�-_______-------_ Rock Filled Yes��o 1❑ <br /> Water Table Depth �- ---------------------- Rack Size _ ��_ ------------------ <br /> Distance ; <br /> � to nearest..-Welly-.__/_a�d.___I---------------------Foundation ---l'o____------ Prop. Line ...._____. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --:----------------------------------- Date __-__________..___________..._-_-) <br /> Septic Tank (Specify Requirements) -r--?----------- ------ --------------------�� r <br /> Disposal Field (Specify Requirements)' ------ --------`---------------- ----------------------- ----------------------------------------------------- --- <br /> --------------------------------- - ------------------------------------------------------------------------------------------- ------------------------ <br /> --------------------------------------------------- --------------------------- ------------------- ----------------------------------------------------- <br /> ------ <br /> (Draw existing and required'ad'ditiori ori Teverse 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 Jodquin 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_issved, I shall not employ any_person,in such manner <br /> as to become subject to Workman's Compensation laws of California." 4 <br /> Signed - ---------- ---- -------------------------- Owner <br /> BY "�/l- ' -- <br /> Title ? <br /> " ' <br /> (If r the ow r) r <br /> .191t DEPARTMENT USE ONLY 4 <br /> APPLICATION ACCEPTED BY DATE I .Y --- --I----------------- <br /> --- = ----- <br /> 'ILDING PERMIT ISSUED ' -- ------------------------------------------=--------•--------------DATE -------- -------------------------------- <br /> "ITIONAL COMMENTS ---------------------------------------- ---------- ---- -`----: ------------------------=----.=`=='.' ;---------------------------- <br /> ..---------------------- ---------------------=----------------------------- <br /> '-�' �'`�`° '`�,�` --------------------------- <br /> --- --- -- <br /> --------- <br /> •tion by: r------�� - <br /> ---- - ---- Date - <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT - � <br /> -'68 Rev. SM - <br />