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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />--------------'-:....... •---•-- ...-•---- (Complete in Triplicate).... . Permit No. ��:.. .�. . .. <br /> , <br />.......................................................... <br /> 11, <br /> Date Issued /P-�........ ' <br /> ............. ..... This Permit Expires 1 Year From Date Issued <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 tis made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION/.�.'.31D----•`)...-•-------------........ !..... ..... ... ---...CENSUS TRACT .------•-- -------- ...... <br /> Owner's Nome! _.d+ ..�p-Sart-Qq,�?_.: .----- �......')C. t- = Phone .......... <br /> Address ...........1. -� (J-cbc1J.__.Q�eti -... - --- --.... City _ _._..- <br /> [� <br /> Contractor's Name ... . <br /> .License #,f Phone .............................. <br /> ' t <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 ............................................ <br /> Water Supply: Public System and name ------_----------------- --------------------------------............---.....................Private �. <br /> to a depth of 3 feet: Sand❑ ,Silt ElClayClay E] Peat E) Sandy Loam ❑ Clay Loom <br /> Character of soil L_%/ ............................ <br /> Hardpan AC] 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.) <br /> NEW INSTALLATION: (No septic tank or seepo a pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 1 Size.. --• _- -- `.��•�..------ Liquid_Depth .... ................... <br /> Capacity ...... Type . ................: Material_._.__ No. Compartments % <br /> c <br /> Distance to nearest: Well ..��6 ..------Foundation .4_04-47:.... Prop. Line ... _ .........-_. <br /> LEACHING LINE [,/,"No. of Lines Length o++f each line.... Total Length 2P ...................x <br /> 'D' Box ..... Type Filter Material -----S.7\......Depth f=ilter Material -...``I ` ..............-.--._..___.._..� <br /> Distance to nearest: Well ........ _ Foundation Property Line -..- .a......_ <br /> SEEPAGE PIT JV1 Depth Diameter ----- <br /> Number . ._- _-r -:._._-------- Rock Filled Yes l❑ -� <br /> Water Table Depth ..._- -._-- -_ .a--'_•___Rock Size _.-JVI'_•e f..x�.,_-"• rr ��-- <br /> Distance to near6tt: Well-„,----..._�-e?: ?.._� �-._____Foundation -.... _ Prop. Line .- ..i !_.-..... <br /> F <br /> REPAIR/ADDITION(Prey. Sanitation Permit ....................... Date --------------------------........) c <br /> -- <br /> SepticTank (Specify Requirements) ....................... .---------. --•--••-------------•...._._... ------------- • '.................._..................................... <br /> Disposal Field (Specify Requirements) .-_..._.._--.----- .- i <br /> ---------------------- ---------- .......... .........- -- ------- --------. .............. ---•--....... . -------------- <br /> (Draw <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. Nome owner or Ilcen- <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 Compensation laws of California.” - <br /> Signed .:.. . ... ..... ................ Owner <br /> - �_ Title . "y">.... . <br /> -- -------- ------ <br /> BY , <br /> (if.other than owner) <br /> _ FOR DEPARTMENT USE ONLY--- <br /> ACCEPTED BY ..... '. � DATE ...10 . <br /> APPLICATION 1�.-1..... <br /> . ..... ........-... . ..--------•- <br /> BUILDING PERMIT ISSUED ....-.. . ... 0­0...._ --------- ------------ DATE _...... ........ ...... <br /> ADDITIONALCOMMENTS .... ... .......... ----...............---------- ------- •. -•----.....------.. --...---._....-- ...................................................,.- <br /> .................•--'----i----------------........................................-----------..................................._.........................................-..._.-------... .............. <br /> . ....... ......................... <br /> f <br /> i ; incl inspection by ��. Date ..�. ....--......------- 1 <br /> --.. <br /> ','' `'SA'N ..JOA4It:ilf LOCAL- HEALTH DISTRICT ty <br />