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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. .-.-....... <br /> ........................................................ ,r <br /> -„--,•,,,,---„---„- ...... ............ This Permit Expires 1 Year From Date Issued <br /> Date Issued Z5�7a4.:Z5 <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 /> JOB ADDRESS/LOCATION _..y .X53..-. E!.--.CAYYaL To�Y..../ r�.:...................CENSUS TRACT .......................... <br /> be <br /> Owner's Name ................ -- ..... Phone - ......... <br /> Si�M• - City �I�QN..........:..... <br /> Address ................ ... ........-........ , <br /> Contractor's Name :...'. ._.....License # / 6 &6:::: Phone ..�....... . ......�.. <br /> Installation will serve, Residence 0 Apartment Housefl Commercial❑Trailer Court 0- <br /> Motel <br /> •-Motel ❑Other ........m......... <br /> Number of livingwnits:..../------ Number of bedrooms.',3-.....Garbage.Grinder ............ Lot Size eS <br /> - <br /> Water Supply: Public System and nome ....:......:..........................},-...-- .........._..:-----................................... Private i to......... r IN <br /> Character of soil to o depth of 3 feet: Sand jM ,Silt❑ Clay ❑ Peat❑ Sandy Loam:❑ Clay Loam❑ <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 aide.) <br /> NEW INSTALLATION:- (No septic tank or seepage pit permitted if public sewer is available within 200 feel) ' <br /> PACKAGE TREATMENT [ I SEPTIC TANK'{ j Size..--.KA.S 9 _ <br /> . x_ ........... ...--...: Liquid Depth ......*................. <br /> . 0� <br /> _. <br /> Capacity .JAM ..-- Type Pyo !/?!T Material.--. No: Compartments ...�................ N <br /> - <br /> Distance to nearest: Well --...... OO..'.....:..........Foundation ..... o .......... Prop. Line .... t%.......--... lY <br /> LEACHING LINE [ j No. of Lines .... . .:........... Length of each line.....: �ja'�� �Tatcl length <br /> 'D' Box ..../-...... Type Filter Material_!rje4:r�:::.:.-Depth Filter Material ....... 0 r� <br /> Distance to nearest; Well .:_���.�..r-.::. Foundation ....!�A .......... Property Line ...... . ........ <br /> SEEPAGE PIT '[ I, Depth _.................. Diameter -:......-.-..--: Number ..............--.........:.. Rods Filled Yes ❑ No ❑ <br /> Water Table Depth ........ ........ ..............---Rock Size ...........................--... ” ! <br /> Distance to nearest: Well ..............................:.........Foundation ................ Prop. Line .........--......... 0 j <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........:.....................:............. Date ...................................I <br /> SepticTank (Specify Requirements) ...............:...............---...................................... ......_....--................_......-....................... i <br /> Disposal Field (Specify Requirements) .......:-:------------------------------- ----..........................---------- ...................-.................... <br /> .-.. <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 Sari JoaquinLocal Health District. Home owner or licen- <br /> sed agents signature certifies the following: - <br /> "1 certify that in the performance of the work far 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 ......FiA ...T/ani r Sore: Owner <br /> By.............. J iHe - -..... <br /> ......:..................::.................. <br /> . <br /> pf other t er) <br /> FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY..... .. ... . ... : . . ... .....:...5.»._.......:...........................-. DATE ....IL- /B.0 V........... <br /> BUILDINGPERMIT ISSUED ................................................ .......:-:._..................- ..................DATE ........................................... <br /> ADDITIONALCOMMENTS ................:..........:......... ... - -:",.:---- -.- -:---.--..-:......... ......--..--................-:........:..................... <br /> ............ <br /> ... <br /> .................... <br /> ........ <br /> ................................. <br /> .........._.. ------- -.....------ ..:....._.....•-..----..-.... .--.-...--....-.-.....--.-......-.................................... <br /> . _ _ _.-.. <br /> _y�y•� .. .... ..�� i <br /> Final Inspection by, ....:.....---- Date ... ..y--:�"...... .----- <br /> ----• <br /> ................................... . . . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7/723M <br /> a u 1.3 24 I.-AA a. �w,t <br />