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G FOR OFFICE USE: n :L;{ ;i <br /> �,y APPLICATION FOR SANITATION PERMIT <br /> ........................................ <br /> >. (Complete in Triplicate) Permit No ; <br /> ............ ......... ............. ........ <br /> r Date issued <br /> :.................................... This Per Expires 1 Year From Dot*Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the:workrherein rr <br /> described-This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulat,orts`f , ��� ��s <br /> ! ; . JOB ADDRESS/LOCATION .... �. // r CENSUS TRACTS r <br /> „ �.. . ,� .........�G I..CJ.. �....,,�G . <br /> ,r 4 Owner's Name ...-..-! c!.'.�1...,: t i�J✓................................................... .............. .......Phone ` r <br /> ` • Address.:.... ..r.. .��::.... ................................................City _ :!?.Gy <br /> xContractor's Name ... ' j T.r-..........:...... License <br /> r , Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court <br /> a E Motel❑Other............................................ <br /> Number of living unrtr....f..... Number of bedrooms ._11 Garbage Grinder��.�r.. lot Size /xX � <br /> Water Su 1 Publics stem and name g'r ' � <br /> pp Y Y Pr,vate # rp F <br /> Character of sail to a depth of 3 feet: Sand f] Silt❑ Clay ❑ Peat❑ Sandy Loam r Cfay Loam ❑Y f '*M <br /> Hardpan© Adobe ❑ Fill Material ..._. ...... If yes; <br /> j�Ln <br /> (Plot plan,,showing size of lot, locaticn of system in relation to wells, buildings, etc. insist be' placed:on reverse side IA <br /> } NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet I a ; <br /> r ray a. <br /> PACKAGE TREATMENT [ I SEPTIC TANK t I Size................................ Liquid Depth <br /> ( Capacity ..................:. Type .................... Material.......... .. ........ No Compartm9nts <br /> ,r Distance to nearest: Well ............... ................Foundation Prop`line <br /> Total!,Length .. <br /> { No:. of Lines Length of each line.. <br /> LEACHING LINE [ I ... ................ . 9 -. ... g <br /> i <br /> 'D'.Box ....... . Type Filter Material _...................Depth Filter Material <br /> s Foundation Property Line *gib ' <br /> SEEPAGE PIT. `,esiT�nce to nearest; WDell ................... 'a"Y <br /> .. . '. G p _.............. N b [n1­,;,:;Nom] I <br /> t Water Table Depth stet ................ Numbe <br /> eRock Size Iled <br /> Diameter Rock Fi Yes <br /> Distance to nearest: Well ........................................Foundation ... Prop Line <br /> x REPAIR/ADDITION(Prev. Sanitation Permit# ......................... ...... ..... Date ......... :.:j Ri <br /> Septic Tank (Specify Requirements) ........................... . :. �K r <br /> w <br /> oe <br /> F: Disposal Field (Specify Requirements) ......}�rJ....../ +..J! °. !'I-•..(� �••••.../' / �Qr .rr�f ziS <br /> b� == . <br /> .V....................... . ..............................._.............................._ k� <br /> }„ .. six h:� i <br /> a <br /> x � <br /> Y : <br /> 4 "ad x <br /> (Draw existing and required addition on reverse side). <br /> R 1, hereby certify that I have prepared this application and that the work will be done in aceordan with SanJou ii;r <br /> (: County Ordinances, State Laws, and Rules and'Regulations of the San Joaquin Local Health D'+sfrict�ome owner�or Iicen- )+ <br /> i sed agenis,signature certifies the following: <br /> *{i "I certify chat in the performance of the work for which this permit is issued, i shall not tmploy any person in such manner �, <br /> �I. <br /> as to become subject to Workman's Compensation laws of California." <br /> '`. Sionec! . . ................. _..:.... _.. .... i! .... Owner <br /> r By ......., :....:. .... ..... . �.'.....�m'G �,� ........ Title . L4 f?G� y <br /> 4 <br /> Z <br /> If o anowner) <br /> ( <br /> FOR DEPARTMENT USE ONLf1 <br /> y. s ,$' <br /> 1 APPLICATION. ACCEPTED BY ........ .. ................. .. lL yiI'r` t�:�i /,:�._. <br /> DATE'.,.,./,.-_r�"� U v { <br /> K_ I <br /> BUILDING PERMIT ISSUED... ..... ........ .... ...... ...........�......, ............ .._ .�,�..._.........DATE .... ....._ <br /> ADDITIONAL COMMENTS ''... ..... :......... <br /> ..... .................... <br /> .... x <br /> ...........'-....: <br /> ................. . . . .. . .... .. ...................... ..... ....... <br /> F x <br /> ........... ... .... ........................ . ...... ..... -� ... <br /> ...... . ......... ..... . - ... ...... . . ... . . - ......� , r _..-•�;.:. .. .... ___....-... ; ,i. <br /> ..., .: C1. '(/<J.: Date :..0 .i <br /> Final Inspection by: .. . ,�...... ✓ <br /> I SAN JOAQUJiv_.EOCAL ki TH. ISTRICT <br /> E. H. 9 1-'E8 Rev. SM x <br /> SII <br />