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-FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. .......... a7 <br /> This Permit Expires ? Year Frons Date Issued Date Issued ..`....-...---�� � <br /> Application is her made to the San Joa in Local Health District for a permit to construct and install the work herein <br /> described. Thi pplication is mad o nce with County Ordinance No. 549 and existing Rules and Regulations: ' <br /> /yx6--V <br /> t <br /> JOB ADD ESS/LOCATION ....... ...... .?F�. ...C..r..� .6...U`r. ...CENSl15 TRACT .....•.................... l <br /> Owner's Name _. __ ..� ..... :F.. t.-..--...................................,.....................................Phone 3A /3 /fL <br /> Address ...................... City .... .4 /..,.............-.........----..............._.........---- <br /> Contractor's Name --- . . ' .. . . ..................License # 6-: Phone <br /> �.,��..........,.--� <br /> Installation will serve: Residence ffA-partment House] Commercial QTrailer-Court 0.- <br /> Motel []Other............. ............... ::...-:....._ <br /> • <br /> Number of living units:..._/..... Number of bedrooms ...3.....Garbage Grinder .... Lot Size ......�.�2.. .X../.��............... <br /> Water Supply: Public System and name :-•-.- a f1 y. ! �1... .�c 7..�?....L��.�5: .............. ..... .. ;.Private E3- <br /> Character of.soil to a depth of 3 feet: Sand a Silt[J Clay 0 Peat 0 Sandy.Loam 0 Clay Loam D <br /> Hardpan 0 Adobe Q Fill Material ............ If yes,type <br /> ...... , <br /> (Plot plan, showing size of. lot, location of system in relation to wells, buildings; etc., must'be•placed an reveres aide.) <br /> NEW INSTALLATION: (No septic tank or seep e'.Pit:permitter if public sewer.is_available_within.240..feet,l <br /> PACKAGE TREATMENT SEPTIC TANK . Size......... ................................ Liquid Depth <br /> Capacity'.L?C7- . Type (�Q_ru- ... Material...............`.. No. Compartments ...................... <br /> 1. 01r <br /> istance to nearest: Well ----------r:.......... Foundation .. .... Prop. Line .. d........... <br /> LEACHING LINE [ No. of Lines .... .Z Length of each line. a .... Total Length -e�lt�0 r <br /> - g <br /> 'D' Box ............ Type Filter Material _. ...!Z9C.Depth Filter Material -. _.... ��. ........... <br /> Distance to nearest. Well ........ ............. ...... Property line-' ; <br /> ---_-..._ Foundation .-.�.._..._ .._.... .. � <br /> SEEPAGE PIT [ ] Depth Diameter ----------------Nurnbei... ............... Rock Filled Yes [3 No Q <br /> �r <br /> Water Table Depth -------------------------------------- ---------stock Size ..... <br /> Distance to nearest: Well ..... ------------Foundation .................... Prop. Line ............_,.:....., r <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----_-------.--_---•..........:...........Date...................................I <br /> SepticTank (Specify Requirements) ......-•...........- ............................................... ....--......................................................... <br /> Disposal Field (Specify Requirements) ------------------------------..................___................... ..............................I................ <br /> ---------------------------•--•---------------- --- --......---•----•------------------- ............................................................_._.................................... <br /> ...... <br /> ---------- ----------------------------------------- -------------------•..-------•-•-----------------------................................................................ <br /> (Draw existing and required addition on reverse side) <br /> I 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 Health.District. Homo owner or licen- <br /> sed agents signature certifies the following: w <br /> "I certify that in the performance of the work for Which fkis•periiiit 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 6 Ger- .__ .�� ------------ --_---•------------- Owner <br /> By `-e i <br /> - ...__....- ------- -- ------------•------ <br /> (If other than owner] Y <br /> FO DEPARTMENT USE ONLY s <br /> APPLICATION ACCEPTED BY ----___//---_-- - .- -----•-• ..................... DATE ..... •--------- <br /> •-• <br /> BUILDING PERMIT ISSUED --------------• _...-- -------•...............--•----------------------------------..-..- --•------.....DATE ......... ................................... <br /> ADDITIONAL COMMENTS -------____-------------------------- - <br /> -------- --------------- ------------------ ------------------------------------- -------- --- ........ ---.---•--------------............._ .......... ; <br /> -------------• .......I----------------------------•-----....................------------------------------------- ------•----------. ------- ........................-................... <br /> ...................... . <br /> __ = = ................ <br /> Final Inspection b .....................•-.---...........----......._..Date _.......... <br /> EH 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M i <br /> s <br /> s <br />