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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..............:!n ;' <br /> {Complete In Triplicate) permit No, . .. <br /> ........................................... Date issued <br /> This Permit Expires t Year From date Issued <br /> Application is hereby made to the 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 /> 310-�-_-�,_ ? <br /> JOB ADDRESS/LOCATION .._.------ _ i0kW .....!.7............p .�'S. g ..........CENSUS TRACT` .................... <br /> Owner's Name /�-t!.1�..._ ._...._. /)%i-L <br /> ....Phone ......s." Y`4'9 b' <br /> Address ............ .................. City ....73.x!.. <br /> Contractor's Name __�i ----------------•----••----..License # Jd-✓ E-... Phone <br /> --------.........--•--...----- <br /> Installation will serve: Residence Eg Apartment House Commercial❑Traller Court ❑ <br /> Motel ❑Other............................................ <br /> Number of living units:-•-_ ------ Number of bedrooms --. ------Garbage Grinder Lo!5lze ... ..#9 cY fix..................... <br /> Water Supply: Public System and name ...................................................................Private, , <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ beat❑ Sandy Loam ❑ Clay Loam 0 <br /> Hardpan❑ Adobe❑ Fill M6terial ............ 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 pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] size.......... 7!............... Liquid Depth ----- ............... <br /> Capacity - Type Material_. ...... No. Compartments ... ................�y <br /> /06 ...... Prop. Line ... p. .......0 <br /> Distance. to nearest. Well ----------------------------•--•_---Foundation ---.1....0.._..... <br /> LEACHING LINE j ] No. of Lines .......3............. Length of each line......?a f Total Length '�9'd ` <br /> .._.... Type Filter Material .. ° ..._..Dep#h Filter Material ......%Zp " <br /> 'D' Box .... ........... <br /> Distance to nearest: Well _...l��r..f Foundation -- �--- --...... Property Line ....... <br /> ..... . . ........... <br /> SEEPAGE PIT [ j Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No Q <br /> WaterTable Depth ------•----•-------------------•- •-------_-•-Rock Size ------------------------. ------ it <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........... ...........................•--- Date ................... <br /> ) j <br /> SepticTank(Specify Requirements) ....................-............................•....................................................................._......_...._........--- <br /> Disposal Field (Specify Requirements) ---------- -•......................................................... ----------.:..................... <br /> . <br /> ................................................. -----------------------------------------------------------------------•...................................................................... <br /> ......_-• <br /> (Draw existing and required addition on reverse side) # <br /> 1 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 liven- �p <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .... `• ,#Vr.`>-- ----------- Owner <br /> E _ <br /> (If other t caner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ --- ------•------------------------------•----------------------•---------------. DATE ... .............. <br /> BUILDING PERMIT ISSUED ------ -----------------__------------- ... -------- - DATE ..........---...._... .... . <br /> --- •---- <br /> ADDITIONAL COMMENTS ----...---•--.... • ---••---•---•--•----•-•-•-•-•--------------•-------.....-•----.... ............................ ......-.............................. <br /> _..... <br /> ----------•--------------------------------------•-•-----•-------------- <br /> - --------------•--------------•-- ---------•--------•- -•-•-------------•--------------•-•--------------- <br /> -------- --------•------------•- ------------••---•--•--------------•-------------•-----. -- .................... -- .._........... <br /> ------------ - - <br /> Final Inspection by: .---------•---------f-'' a-------------------•--------•----•-•-•----•.......... --I—........I.._-•--- .._.....Date ..�..��.��............... <br /> EH 13 2L 1-68 Rev. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />