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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT "A -7�- 179 <br /> ...................... ---...... ............ 7�-� ( v <br /> (Complete In Triplicate) <br /> Permit No. ..................... <br /> .. . ...... This Perrnit Expires i Year From Date issued bate Issued <br /> .. <br /> Application is hereby made to the San 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 /> 14' <br /> JOB ADDRESS/LOCATION -- j�y. w� !._..-3..3.. .... °�a' .... -.... CENSUS TRACT <br /> Owner's Name ....... �� `, as f� ; f� — —•: one 33�'.Y.... ., 9'k <br /> ....�_.......__... --•----- ...........Ph ......---...... .._.. <br /> ._. . ` <br /> ._ .Address Scity . Yfd.G.X ....---•--.. . ...................... . ......_. <br /> Contractor's Name -- '- acv T"Via_v: �±_ 5 c'�1' ...License # ... Phone <br /> Installation will serve: Residence®Apartment House fl Commercial❑Traller Court ❑ <br /> Motel ❑Other----•....................................... <br /> Number of living units—J...---- Number of bedrooms ..3.......Garbage Grinder ............ Lot Size _-• ---- .`... �.. .................... <br /> Water Supply: Public System and name ----------••-------•---- ----------------------_--- <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat O Sandy Loam Q Clay Loam 0 <br /> Hardpan ❑ Adobe ❑ 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.) j <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...y`.! 3�X l..`.................. Liquid Depth ..... ................... <br /> Capacity _t o---------•- Type 13" cm,P Material----------- .G--__-. No. Compartments ..a................ <br /> Distance. to nearest: Well .....f Obi r <br /> --•--...................Foundation ..... ............. Prop. Line ..Sa............. <br /> LEACH] G11 E [ } No. of Lines -------_V--------------- Length of each line.........................._ .c. J <br /> Total length ............... ..........0) <br /> I�U G�� u <br /> 'D' Box ...t------- Type Filter Material ------•.............Depth filter Material .................................... Apt-" <br /> Apt-" <br /> Distance to nearest:•Well .....�_�� Foundation U 5 <br /> -•---...-- ........................ Property Line ...... ...`............. <br /> SEEPAGE PIT ( } Depth -------------------- Diameter ................ Number .--------_---_- ......... Rock Filled Yes ❑ No 0 Vs <br /> Water Table Depth ................................................Rock Size •............................... <br /> Distance to nearest: Well .............. ...... Prop. Line <br /> ------•------•-------.....foundation -------------- ............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------_--__.......----- Date ._••--............................1 O¢ <br /> Septic Tank (Specify Requirements) ................................................................................................................. ................--...... <br /> ul <br /> Disposal Field (Specify Requirements) --------•--•-----------------_----_----- ----------------------.-------------------------------------------.......I.......... <br /> ----------------------------- <br /> --------------------------- ............—................ .......... ''� <br /> (Draw existing and required addition on reverse side) <br /> 1 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 Heahh;Dtstrict. Home owner or llcan- <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." A , <br /> Signed 6­d_",/ -------rsb!V. Owner �{ ( <br /> By <br /> _------- Title ............ <br /> (If oThREFF1105 owner) <br /> FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY ----- ----- •--•' ----------------• ----------------------- ------------------ DATE .. 3 7 •---_..__ <br /> BUILDING PERMIT ISSUED ------- ......................•-•--------------------------- <br /> -------------------------------------------•---•-----.-DATE .................... <br /> ADDITIONAL COMMENTS <br /> ---------- ------------------•- .......... ------------------------.... ----------------------- <br /> . .................... <br /> --------------------------------------------1.11------ <br /> FinalInspection by= ---- -----------------------------•-••----- ...............................................--------------------Date ...- 3 ..7 . <br /> EH 13 24 1-68 Rev. _qI .._._.. .... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br />