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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ -- 7 <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From Date Issued Date Issued ._-!-l_0__-11, <br /> _ _ __ <br /> --------------------------------- _.-.-.. .. _._____ <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- / .z ' k-_ '1,_________ __ _ _ - CENSUS TRACT __________________________ <br /> - ---------------------------------------- -------- <br /> Cf <br /> Owner's Name --- - - tom`---- A' - ----------Phone ------------------------------------ <br /> Address -------------- � ----------------------- ------------------------ <br /> Contractor's Name ._ .- _ _._ ��-rte-_ _______-_'`c-4License # -�0-8. �' ----- Phone _.._._.__________________.. <br /> Installation will serve: ResidenV [Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other ------------------------------------------ <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'❑ Silt❑ Clay 0 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,) v <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [YS Size_0l�j _ �__X__'s ; Liquid Depth __ __�_____________ <br /> Capacity _�_ k - Type , -- ---- Material__C-s�`_-_ No. Compartments ----------------.-- �"� <br /> tJ � f � <br /> Distance to nearest: Well ------- o---r_________________Foundation _._!�-____-------- Prop. Line __S.�_______-•-___ <br /> __________ Length of each line___.____7_t.i---------- Total Length -----I S_a ` -- <br /> LEACHING LINE [ No. of Lines ------� g <br /> D' Box Type Filter Material ___��1. ......Depth Filter Material _____-_]_ ________________________________ <br /> Distance to nearest: Well ----Hi?_.'_.___._____ Foundation ------ ©------------_ Property Line ---r__--__-___-__-_-___ <br /> ' __ Rock Filled Yes No <br /> SIT [ Depth Q 5--x `�----- Number Ql <br /> i <br /> Water Table Depth ------------------��-----------------•----Rock Size J-1h-- - <br /> Distance to nearest: Well -------------[faQ_................Foundation ---112---i-------- Prop. Line -----5__-___-_____- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------------------------------------------ --------------- --------- ------------------------ --------------------------- <br /> DisposalField (Specify Requirements) -------------------------------------------------------------- ----------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------- <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 licen- <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 ------------------- ------- r Owner <br /> BY --------------- --------- ------ <br /> Title �'-etx � C� 4'--- --------- -... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- _'--�--------------------------------------------------- DATE ---- '^-tel �------•-•---- <br /> BUILDINGPERMIT ISSUED ---------- -------------------------- -------------------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------- -------------------------------------------------------- ------- <br /> --------------- -------------- ---------- ------------------ --------------------------------------------------------------------------------------------------------------------------------- <br /> ---- -- ----- ---------- --- - - - --- - ------- ---- --- ----------------- <br /> ___________________________ ______ ____ ___ _____ ___,Q(.._._.._-_______________-__-____________________.___-__-___--____-___-____ <br /> Final Inspection by: Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />