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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....................................... Permit No. ..y J�6 . <br /> (Complete In Triplicate) <br /> Date Issued .3'........:..... <br /> .........................._.._----------------._..__... This Permit Expires >I Year From Date Issued, <br /> Application is hereby madte San Joaquin Local Health District for a permit to construct and ins the work herein <br /> described, This applicati n is made in compliant with County Ordinan a No. 549 and existing Rules and Regulations: <br /> 3 'y <br /> JOB ADDRESS/LOCATION ... :g--_:'}�_..:�.._. _..._ y_1.:�...__��?*-�--��_..1.�.��C.....CI=NSUS TRACT ...:.._.. �......_..Ca`j� <br /> Owner's Name .... � Phone ...................... <br /> ........... <br /> w <br /> Contractor's Name .. - - --- - .a-• . ..... ::.. ..... ......�Q..........License # - Z---- Phone ....................... <br /> Installation will serve: Residence Apartment House Commercial ❑Trailer Court I] <br /> Motel ❑ Other ............................................ <br /> Number of living units:.... ..... Number of bedrooms .._ �.....Garbage Grinder ............ Lot Size J__ :............. <br /> Water Supply: Public System and name .......................---................................... a-r........................................Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay E] Peat F1 Sandy Loam 9T--,Clay Loam [3 <br /> Hardpan C] Adobe 0 Fill Material ............ If yes,type ............................ •� <br /> (Plot .plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) W <br /> NEW INSTALLATION: (No septic tank or seep ge pit permitted if, public sewer is available within 200 feet,) GJ <br /> d j /. <br /> PACKAGE TREATMENT ( ] SEPTIC TANK i Size. _— .2............. Liquid Depth ..`1 __x ......_..,..... <br /> ! <- t m <br /> Capacity .1�.�_tF._--___ Type .. Materiai_I� < No. Compartments -. ..... <br /> Distance to nearest: Well ____.._-._`_04. ..........Foundation ...1.�?.. ------ Prop. line ...-V...... <br /> . <br /> LEACHING LINE �� No. of Lines _.__.__ _____._ Length of each line._____7_____ kt <br /> �.__.._. Total length / ��. C <br /> -- 4 <br /> 'D' Box -----I------ Type Filter Material ------------�_-•--.Depth Filter Material ..... ..`. ................•_....._......� <br /> r <br /> Distance to nearest: Well ......1._rQ_ Foundation ___-_�. _ .____ Property Line ..._:. <br /> [ ) Depth, ......h5_.l.-L 04somles-Z(.!..L1VNumber ....... ;. ...,......... Roc Filled Yes No ❑ 'J� <br /> Water Table Depth *.4_�...._ /Wl .. r <br /> ` --------------- ----• ----....Rock Size .._... ....... ..__. <br /> Distance to nearest: Well ........J.aQ---- <br /> _�.--•-_,----Foundation -.__ Prop. Line ..... ......... I <br /> REPAIR/ADDITION{Prey. Sanitation Permit# ............................................ Date ..................................I { <br /> Septic Tank {Specify Requirements} ................................. ----- <br /> .............................--------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------- -•--••-•..................:....................................................................._.....-•--------- <br /> ---•................•------•--......_................._.__...-•---•-•....._....--•...-•---••-••-••----...----------- •............... --------- ........I......... <br /> ._..._ <br /> ..................----------------------------------------------------------------------------------------------------------------•------------------------------------ ---------••...................... <br /> . <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 /> 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: I "` -,t <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 Compensation laws of California." <br /> Signed -----------------------------•---........ .. ... ............. Owner <br /> By .__._......................•- ._............... :. '-`, .::Title ' -�� u.r........_-............................ <br /> (If other than owner)- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY .............: ..-:.----------------------•-------------------- .................................... DATE ........... .. ...... ..��........... <br /> BUILDING PERMIT ISSUED ------------- ............................................................DATE --•........................................ <br /> ADDITIONALCOMMENTS ...................................................................................................................................:........................... <br /> ....----•........................................................ ....................................... ................................................. <br /> .................................. -----------------------------------------------------------...............--------------------------------------------------------------------------------------------- <br /> -------------------- ------------------------------ A41201 - -- .. <br /> Final Inspection by: ..... Date ..�� <br /> SAN JOAQUIN LLOCAL HEALTH DISTRICT s. <br /> u <br /> 13 24 ,ca o .. tax 7177 1 %f <br />