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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> lComplete.in Triplicate) Permit No. ..................... <br /> ............................... ......... <br /> .................................................. This Permit Expires 1 Year from Date luded Date Issued . .. :.:....... <br /> P <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 /> 10I3 ADDRESS LOCATIO <br /> q ,G. <br /> / .1.........R",i.�.iP��..�-,���t. ..........CENSUS TRACT . ..................... <br /> Owner's Name -........_. EJi ---•..A! ..................................: .....................:.............. ..._......._. <br /> w , .. ..Phone .��,�� <br /> Address -..__.ea� ` • lN _ � ._.._ ........... = .. City .� ...... /+ <br /> Contractor's Name ..... .._... . 2W_...................:......License # ... Phone �.. <br /> Installation will serve: Residence 10 Apartment:House fls Commercial oTraller Court 0 <br /> Motel ❑Other-,-­........................ I....... <br /> Number of living units:--../... Number of bedrooms ..:_.Garbage Grinder...... Lot Size -..........:................................. <br /> Water Supply: Public System and name " <br /> ...Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay 0 Peat❑ r Sandy.Loam.0_ .Clay_Loam 13 � <br /> Hardpan 0 Adobe ❑ Fill Material ............If yes,type..........:.... ........ <br /> .... ' <br /> (Plot plan, showing sire of lot, location of system in relation to wefls, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: ' INo septic tank or seepage pit permitted if public sewer is available within 200 feet,( <br /> PACKAGE TREATMENT ( ] SEPTIC TANK f ] Size___................. ..................... Liquid. Depth °....._..__............_.-- � <br /> Capacity ..------------------ Type ............ Material.---.. ... ........ No. Compartments <br /> Distance.to nearest: Well ------------------------------------foundation ............... '°Prop. Lime ....................... <br /> LEACHING LINE ( ] No. of Lines --------------- ---- Length of each,line---.... .__....•--.-°.` Total Length ........................... <br /> 'D' Box ............. Type Filter Material ....................Depth .Filter Material .....: ......_. i <br /> .Y <br /> ------------ - <br /> Distance to nearest: Well ......--.-•............. Foundation .-t.__..... .'...°_._. Property Line € <br /> Y <br /> .SEEPAGE PIT ( ) Depth _Depth Diameter ---------------- Number:..._.. ___.._.'.......� Rock—Filled Yes ❑ No 0 <br /> Water Table Depth ................................................Rock Size .. ..... <br /> Distance to nearest: Well ..........:.....................:.......Foundation ......... ._:. Prop Line --------•----------_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit•` -----:----------------............. ....•>-=.Date .-:....................... <br /> Septic Tank (Specify Requirements)......... .......................... -- l <br /> .._. <br /> Disposal Field (Specify Requirements) -- ......6. .... 24........ <br /> ..... .......................• <br /> •• - --- <br /> #Drow existing and required addition on reverse side) , <br /> I hereby certify that I have prepared this application and that the work will be done,ln_accordance with San Joaquin <br /> County Ordinances, State Laws, and. Rules and Regulations•aI the San'Jaartuin Local Health:District. Homo owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for whlch 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 /> � s <br /> Signed ----- ,-. <br /> -•--------- - •-• -- --- -- -...�- - -- -- ....----•--•---------------.Owner � ,,. <br /> BY -- <br /> (if other than owner) <br /> FO PAR MENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------- -.................. <br /> ---- ---------- - --- ..... <br /> = . DATE ..- .Z. 2 7 ... <br /> BUILDING PERMIT ISSUED <br /> _.. - ----------------- ••---•-- ---------•----• -• .. DATE .... <br /> ADDITIONAL COMMENTS . .---•--------•--- <br /> -- -------- ----=----- --- J ------ -_--_---_-..............................................................._._.-_.. <br /> Final Inspection by: ..-Date .. �.7 ._� -................ <br /> EH 13 2a 1-66 v. Sit SAN JOAQUIN LOCAL HEALTH DISTRICT B�A 3M � <br />