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FOR OFFICE USE: <br /> 4 APPLICATION FOR SAN1TATiON PERMIT <br /> Permit No: �:�. �j---r7 <br /> �J. --------------- <br /> (complete in Triplicate) <br /> --- -------------- ---------------- --------------------- ? <br /> Date Issued <br /> ---------------- ------------- - This Permit Expires 1 Year From Date Issued . l3—7 U <br /> Application is hereby made to the San Joaquin Local Health District for a permit to �onstruct and install the work herein <br /> described. This application is made in compliance v�tith Co ty Or inance N 549 and existing Rules and Regulations: <br /> ` . <br /> " .0-0 <br /> 1 ' C CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCATION - n <br /> Owner's Name /tk----� A <br /> ------Phone - ----------------- ------------------- ------ --- ---Address ---- --------- -- .�.-�------ ----------. CitY <br /> Contractor's Name ------ 'k^- --- -----=----- ------ ---- License.#1 _/-[).l�Phone <br /> N <br /> Installation will serve: . Residence partment House-E Commercial ❑Trailer Court ❑ <br /> e 3 � � <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------------=------------------------ ; a <br /> Number of living units:-_--_ ------ Number of edrooms ------------_Gdr age 'nder --____.-.-- Lot Size -__.___.f_-- ------ <br /> _... <br /> Water Supply: Public System and name]-- ----- -----f - -�.- ----------- ----------------------------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sande❑ t❑ Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan❑ Adobe Fill Material /Y,,C)--- If yes,type -------------I-------------- <br /> (Plot plan, showingis a of lot, location of"system in relation to wells, buildings, etc. must be placed onsreverse side.] <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer i&available within 200 feet) <br /> PACKAGE TREATMENT, [ ] SEPTIC TANK{;] Size--------------------------------- ' --------- Liquid Depth ------------------------ i <br /> YP - <br /> Ca acit # _ Type ------------------=- Material-__--.------------ - No. Compartments .----------- ------ <br /> PY ------ - --- - <br /> Distance to nearest Well ------------------------------------Foundation ---------------------- Prop. Line ---------------:------ <br /> LEACHING LINE No. of Lines __.______ Length of each line---------------------------- Total Length ----------- ------- <br /> --------l. --------i - <br /> .� 'D' Box ..------`---- Type.,Filter.-Material ---------- ---------Depth_. Filter_ Material._ .---------- --------------------- <br /> ` - Property Line - <br /> Distance to nearest: Well _€._.------------------- Foundation --- <br /> --------------------- p ty <br /> SEEPAGE PIT [ ] ;,Depth -.------:'----------- Diameter --------------'- Number -----------'- ---- - -- -- Rock Filled Yes El No' ❑ <br /> Water Table. Depth ---------- -------Rock Size -------------------------------- <br /> D.istance <br /> ------------------- ------Distance to nearest: Well -- -,-----------------------------------Foundation -------------------- Prop. Line --------------�------ <br /> � r ll <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------= ;'-------- ---- Date -_____---------------------------) <br /> ------------------ <br /> . , .,� <br /> Dios ' ` field (Specify uirements) <br /> Y <br /> ------------ <br /> Septic Tank (Specify Requirements) <br /> ... -----------------------------------------------------------�, -------`- <br /> ----------------- <br /> P -- _ _ <br /> Y 9 "'"`I ------------ <br /> � - -' -----------------------_---- -------_-------------_-------------------------- ------ <br /> ._ <br /> -. <br /> -_--.-___--. ______-------- ----------------------------------------------------_--_.___------- -__----- _-____-----_.---__ _ <br /> Draw existing'and required ad t r <br /> -------- �------ --- -------- - - �( 9� q clition on reverse side) <br /> ; <br /> I 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 Mules 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 perfotmance of the work:fog_which_t,hia-pe*.rnit.is,issued;1 shall not emplop any person in such manner 1 <br /> as to become subject to Workman's Compensation laws of California." -, � <br /> 4 ; f16, �. <br /> _ Owner` ' <br /> Signed r 4 . <br /> ----------- ---�er <br /> -------------- <br /> BY --------------------- Title <br /> e <br /> {Ifhan ow er} �: <br /> FOR DEPARTMENT USE ONLY. s.. - ,. ' <br /> APPLICATION ACCEPTED BY __._( JJ-`-- DATE ; <br /> / 3 <br /> 1�-W�---- DATE �/- -._--- <br /> BUILDING PERMIT ISSUED ------'F------------- - <br /> ADDITIONAL COMMENTS ` ---- --- -, w- _ - a... _., ° _ ----------- <br /> ------------------ <br /> ---- <br /> ---' <br /> -- <br /> ----`,1 ------- =------------- -------- --------- ----- <br /> ,-x '�---- - --- <br /> ------------------------'---------_.__ ! ._..; -------------_---------------------_____.________ <br /> 1 cC- <br /> Final Inspection b � _ ___.gate ------- <br /> `J <br /> --.- -- <br /> P Y� ----� -- =- SIE � - . <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'G8 Rev. 5M � <br />