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�• 1 <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- <br /> ----------------------------------------- --------------- This permit Expires ] Year From Date Issued 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .---I_ --�- - e�--------- 4-'----- '4�- --�'--�------ ------ --.-CENSUS TRACT ---�---Sz ----- <br /> Owner's Name --------6�--_--------M_i!!-�2'�--------------------------------Phone <br /> Address -------I Mev- - i- yt/ ------- I Ao City --o '-O.''-----------------------------------------•--- ------ <br /> Contractor's Name - __ N ¢� '� �� _-_.License # __ "'-✓ - Phone - =-_- __ <br /> installation will serve: Residenceig Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other --------------------------------------•--- ``,, <br /> Number of living units:----J---- Number of bedrooms ---A-----Garbage Grinder ------------ Lot Size /NAY e---.f�--'------14cle. <br /> Water Supply: Public System and name -------------------------------•-•-•--------------------------------------------------------------------------.Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt C❑ � 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 side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'( Size____/ rer/d-------------_____ Liquid Depth ------ ___-_-_----____-- \ , <br /> Capacity - ' O_C-____- Type C-r<�rMaterial---�qy 6 ` '�----- o. pa --- <br /> •-- <br /> Distance Jto nearest: Well ____---1?-------------------Foundation ____� _--,�----- Prop. Line --- Q-..-,_-__-_ <br /> [ ] of Lines -----1----------------- Length of each line----- Total Length --- 4D--------------- <br /> FL <br /> --_---------- �! <br /> LEACHING LINE No. ------- � <br /> D' Boxes,__ -� --- Type Filter Material / 4001-Depth Filter Material -----V?0--------------------------.-..- <br /> Distance to nearest: Well _--re__`_--------- Foundation __mZ '��--__---- Property Line. .-------.-_- <br /> SEEPAGE PIT [ ] Depth_.___-___________ __ Diameter ---'�----------- Number ----------------_.-_____-__ Rock Filled Yes ❑ No i❑ <br /> Water/Table Depth ------------------------ ------------------------Rock Size-------------------------------- <br /> Distance to nearest: Well ---------------------s------------------Foundation -------------------- Prop. Line -------------_------ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ----------------------------- - ------ Date --------------------..__-....____ 1 <br /> SepticTank (Specify Requirements) ------------------------------------- -------- .---p} -----------------------------------------------------------------------------•-•-- <br /> f I ♦� <br /> D,isposal Field (Specify Requirements .--------------------------------------------•Y--- ---- --------------------------- ---------------------------------------_•----------- <br /> ----------- ------------------------------------------ ------------------------------------------------------- ----------- --------------------------------------------_------------------------ <br /> ------------------------------------------------- j ------------------------------- ---- ---- _------------ <br /> � t - <br /> ] 3 (Draw existing and required addition on reverse side)— • _ <br /> I hereby certify that I have prepared-thisapplication and that the-ywork will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules ind'Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: -il" <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 ! _ l�-- ° - ------� � ----------------- Owner <br /> EY .......... <br /> -------- - ---- - <br /> Title ----- ------ ---------------------------------------------------------- <br /> {1f other than <br /> ­-.FOVDEPARTMENT USE ONLY, <br /> APPLICATION ACCEPTED BY ------tt-R--C--_- _- <br /> ---- - --------------------------- ----------------- DATE --- ----- <br /> - <br /> BUILDING PERMIT ISSUED ---- ------------------------------------------------ ---------------------------------- <br /> --- --------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---- ------------------------ ------------------------------------------------------------------------------- -------- ----------------------- <br /> -------------- <br /> ..--------------------------------------- ------- -- ------------------------ - ----- -------------------------------------------------------------------- <br /> ------------------ �-_-- ------- ----- ----- ---------------- ------------------------- ------------------------------ <br /> --------- -------- ---------- -- f <br /> --------------- / <br /> Final Inspection ---- -- - -- Date L AY----------- -------- <br /> --- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />