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FCg.-OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> • Permit No: 7j----q-7 ••--- <br /> ---------------- -------------------------------------- (Complete in Triplicate) <br /> - -----= ------ -------------------------------------- Date Issued :.�U=71... <br /> _ - ------- This Permit Expires 1 Year From Date Issued _ <br /> echereby <br /> ces the Son Joaquin Local Health <br /> District mtlthe work s <br /> rein <br /> dribed Thisapplationimade in co plianewih CoutyOdinara No549 and existing Rules and Regulation : <br /> � ! <br /> CENSUS TRACT _' ------•----------- <br /> JOB ---- ----- 1 <br /> Owner's Name -------------- _Xl1 U_._ ;n1C:---------------------------=--------------------------------=-•-------------------Phone <br /> u ------------------- .----------••--- <br /> Address ------------------------------PiAFKetw'x ------------------------------•----•---- <br /> i <br /> CitY <br /> - <br /> Contractor's Name � tT'-_ 4._�Ef -f_f <br /> License # Phone _-- -------- # <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other .___------ } <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder -----------. Lot Size Arnt--_?_1Q__n__uo-------------- <br /> Water Supply: Public System and name -----------------r------- --------------------------------------------Private <br /> El <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay El Peat ] <br /> Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ® Fill Material ------------ If yes,type ---------------------------- <br /> a <br /> ----------------- ----- <br /> relation to wells, buildings, etc. must be placed`on reverse side.) <br /> (Plot plan, showing size of lot, location of system in , <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ___? <br /> PACKAGE TREATMENT { ] SEPTIC TANK;[4 Size------ ��fa ------------ ------ Liquid Depth --------------------- <br /> Capacity _1$_006-AL--_- Type X_C45 ---_ Material_ct2t1C(1 TF_____ No. Compartments -----7-__-.-.---:•_-• , <br /> Distance to nearest: Wel! ------••--------Foundation -----1-0 Prop. Line __j4-................ <br /> LEACHING LINE M No. of Lines -------3-______________ Length of each line------- !'---------------- Total Length _____.^q <br /> Depth. n , <br /> 'D' Box y _------ ,Type F;Iter_Material� --���-------- ------- Filter. =---=�=_ <br /> , W <br /> Distance to. nearest: Well __�i -,�_--fT`-------- Foundation --.� ----------------- Property Line -----•-----.-.=---- � <br /> SEEPAGE PIT [ ] Depth Diameter ________________ Number ----------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth -------------------------------------- <br /> Rock Size ______-----------------•------- , <br /> Distance to nearest: Well ----------------------- - -•-----------•Foundation--------------------- <br /> Prop. Line -------- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------=-••----------) <br /> Septic Tank (Specify Requirements) ------------------- --------- ---------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------- - ------------------------------------------------ <br /> --------- <br /> --- <br /> -------------- <br /> - ---------------------------------------------------------------------------------------•-------------------=-------'---- ------------------------=------------------- <br /> (Draw existing and required addition on reverse side) <br /> i 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: <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 Co penaation laws of California." k <br /> a <br /> F Signed X------ --- --- --- ----- -------------- ;--------------------%--,-------- Owner <br /> 4 .�� <br /> . - -- '� � ------. <br /> Y ------- ----- ------- --- -- ------- ------------------------------ <br /> Title <br /> ----- ---- <br /> (If of er than owner) <br /> FOR DEPARTMENT USE O LY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------- - --------- DATEJ- {_- _ `'�LJ <br /> r <br /> BUILDING PERMIT ISSUED -------------------------------- --- - -- ------------------- ------- --------------------------------------------DATE <br /> ADDITIONALCOMMENTS ------------------------------ - ------------------------------------------------=--------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------- --------- <br /> - -------- - --- ---- ----------=------- <br /> Final Inspection b ---- ---.Date __--- - �c --------------- <br /> ------------- SAN JOAQUIN LOCAL HEALTH D RICT <br /> C� <br /> c u 0 1_'AR Rav .5M <br />