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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PE�'IT <br /> 7 <br /> (Complete In Triplicate) Permit No. ..................... <br /> Thls Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby.made to the San Joaquin Local Healthpistrict for a permit to construct and install the work herein <br /> described. This application is made in compliance with Couni� Ordinance No. 549 and existing Rules and Regulations: <br /> I <br /> JOB ADDRESS/LOCATI N .. ..7�. . ._. .... t'v�.t a,,.r .l .�.77 � ENSUS TRACT <br /> Owner's Name ...... .. ..'.. t..,--.�- .G.G�ut ,._...._._ �7 <br /> � pp --•.....-•................................ ..... . ......Phone <br /> Address '4s'14,Zf_.. City .. <br /> Contractor's Name -<h 4 - ................License # �,5`�'.'s'.`f3... Phone . . 9607..... <br /> Installation will serve: Residence XApp!tment'House`❑ Commercial ❑Trailer Court ❑ <br /> Motel <br /> Number of living units: I Number of Other <br /> bedrooms <br /> --Garbage Grinder . .. tot Size0...X./- �.............. <br /> Water Supply: Public System and name-__.. .. ..._ .... <br /> ........................ ....................Private <br /> Character of soil to a depth of3'feet: SandSilt <br /> ,..•_____- ❑```� Clay ❑ Peat❑ Sandy Loam Clay Loam <br /> Hardpan ❑ Adobe ❑ Fil! Material-::». ; .. .. If yes, type .... <br /> (Plot pian, showing size of lot, Iacati;on,,of,system,_ relation to wells,') �01ltt ings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: ..'" <br /> (No septic tank'orIseepage pit permittbd[i.f Ou.61'ic'`s4§i,�er is available within 200 feet,) �r <br /> y - L{ <br /> PACKAGE TREATMENT ( SEPTIC TANI� LS'rze..��. .e"'---� . Liquid Depth .., ��....---.._._..-. <br /> I Capacity . Type .-..,-- N(aterial- - ... No. Compartments y - <br /> t.. <br /> Distarlce t " nearest; Foundation `f; .... Prop. Line .X. ......__... n <br /> LEACHING LINE Na. of tines . . Length of`each line. ... 2 0.... . Total Length _ ZO.. ......... <br /> 'D' Box . ... Type Filfer'Mdte:Hal 9wilL:._....Depth Filter Material ...f e .......... <br /> ..-..j_........._. <br /> Distance to nearest: Well -�_.... .. Foundation .10........., _.. Property Line .......... <br /> SEEPAGE PIT <br /> �) Depth. Diameterf,n47x.l0,... Number .. �. . ........... .. Rock Filled Yes � No Q� <br /> pP,*1iV -S4 �,� Water°Table Depth ....... ...............:.... . �l .. <br /> Rock Size ...y... .....�-...._..... G <br /> 70 <br /> •.i. <br /> . . / .._... Foundation ..lO.� ..-.._ Prop. Line _. ............. <br /> REPAIR/ADDITION(Prev. Sanitation fermi �..:_ <br /> stance to nearest: Well ... .. .._... fi�.............. Date ................. <br /> -------.....) <br /> ..... <br /> Septic Tank (Specify Requirements) , ,.Q,Q ..Je <br /> Disposal Field (Specify Requirements) <br /> L. (Dr.ow existing and required-addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be (;lone 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 tlpJollowing: <br /> "I certify that in the performance of the wdek for which this permit is issued, I shall!not employ any person in such manner <br /> as to become subject to Workman's Car�rr F46'tiation laws of California." <br /> Signed ,. Owner <br /> _ _ _ <br /> d%% ...... .. '..... . .. ........... ....... ... <br /> Title <br /> BY ' <br /> than owner) 't <br /> FOR DEPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY �j <br /> DATE J /.. . <br />� <br /> BUILDING PERMIT ISSUED DATE . <br /> ....._..... <br /> ADDITIONAL COMMENTS <br /> .. . ... .... _ <br /> Fina! In , .... ... .. <br /> :..................... .. <br /> Inspection by: ....... -- . - Date .... . .... ..� - . - <br /> SAN JOAQiI LOCAL HEALTH DISTRICT <br />