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FOR OFFICE USE: <br /> 3DAPPLICATION FOR SANITATION PERMIT <br /> ..........................-..................... .PTriplicate) Permit No. ..T!.� <br /> (Complete in <br /> ....................................--............... This Permit Expires I Year From Dat*Issued <br /> Date Issued ..r �..7..�. <br /> 174'SSO—f7 � <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 Ryles an&Regulations: <br /> 3030.. S ,/IfC+Fci✓rY rcS 1 f` ' <br /> JOB ADDRESS/L�TIOI$....e ��?�ev'- ....... /G ✓lin yn�/AJr�XI S TRACT <br /> Owner's Name .. .. fir&° .ee{�C. .. fd.fg.--LL r4 t ...:�.°� f/t.l�i�d.�� . .. Lf <br /> Address ...�n.12:"116. ............ . ---.-........ ..................--....City ---............�...^. ........................................ <br /> Contractor's Nome ..... .. '� � ........................_.License F� ...dt.�-��. Phone %���.7....�/.. � <br /> E <br /> Installation will serve: Residence 0 Apartment HouseO Commercial TXfroiler Court Q <br /> Motel ❑Other ............ ............................... i <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size ... .... ..-- <br /> Water Supply: Public System and name ..............................._......................--....._........................._...............Private �[ <br /> Character of soil to a depth of 3 feet: Sand 0 .Silt Q Clay ❑ Peat 0 Sandy Loam 0 Cloy Loam <br /> Hardpan ❑ Adobe 0 Fill Material ............ If yes,type............................ <br /> [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must-be-placed an reverse-fide <br /> NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet;). y <br /> PACKAGE TREATMENT [ I SEPTIC TANK{ J Size..... .. . ............ .. Depth1:f <br /> X..�ar�(. I.P• Liquid . .-...... <br /> Capacity ...p.. .......... Material...44.'— ----- No. Compartments .. ... .... . .. <br /> �01 - Type •� <br /> iDistance to nearest: Well ....,c. . .tri.....................foundation ....Ir p---------- Prop. Line ......._......._ <br /> LEACHING LINE [ J No. of Lines .... _........... Len th of each line....... �............ Total Length ..�4Q.L .............. <br /> q 'D' Box ...eQrrlType Filter Matehol ..'' ;...Depth Filter Material ./.�............: ....._....:_....... <br /> t Distance to nearest:O Well ............I foundation ........................ Property Line '.............n....... <br /> SEEftcGE PtT ( [ Depth 3. .� �i Diameter ................ Number .... ................ Rack Filled Yes [ ( No Q' <br /> Water Table Depth ------ ....._....t........................Rock Size ...-f• -... . . <br /> . k .. nn <br /> Distance to nearest: Well .......... it .........Foundation. ... Prop. Line .. LL........_. <br /> S REPAIR/ADDITION(Prev. Sanitation Permit# .....................F...................... Date ��1...��{r�--F•..) - <br /> iFSeptic Tank (Specify Requirements) ................-..'-................----...................................._......................_------------------------------ <br /> Disposal Field (Specify Requirements) ---------------•----------.----------................................-..................................--'-`- .................... <br /> -----'........---'-----........'---------"--'.............I.........•...........................--'-•'----..............------........'--"'----...............................................,.... <br /> -------............................................ ...................--....................._..........................----...................................................../...... <br /> (Draw existing and required addition on reverse side) _ '�' <br /> 1 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. Home owner or [icon- <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 .... .. .. .. -' / L �Lt'72 Owner.. <br /> By ...... - .... . Title . _... ......................................... ' _ <br /> ........ ..._.. <br /> (If other than owner) ... ...... ...... ... . <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... . .... .... ... . .......... .......; ........2:? ..- ........._..-........... DATE ..�I �.b..:Z`............. <br /> BUILDINGPERMIT ISSUED .....---------------------------------------.-----..................................I....... .. .........DATE ...................................:....... , <br /> ADDITIONALCOMMENTS ........................................ .--....................._...................................... -'---...........................--.............. <br /> .......... - ............................-----=-----...................................................................... ..................................................... <br /> >' ... ........ .. ... . ...�.. . ..................... <br /> . ............... .... <br /> If - Final Inspection by: .... .. . . . ,� <br /> Date.. .........:.... .. .............._....... <br /> r ::::::::::: ::::::::::::::::::::::::::::::::.:::::::::::: : :::::: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 7/723X <br />