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FOR OFFICE USE: G <br /> -� 0 APPLICATION FOR SANITATION PERMIT 'S r f 5 7 <br /> .........._.._..............--------------- <br /> •--• Permit No: . <br /> (Complete in Triplicate) <br /> This Permit Expires f Year From Date Issued Date Issued .................. <br /> .................... ...........-- <br /> Application is hereby made to the Son Joaquin Local Heatth 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 /> p r� _ <br /> JOB ADDRESS/LOCATION _.Ci4. -`-.-- _R...---.._.Lk� ---------------- ----------------CENSUS TRACT .----�-�^�-.----------- <br /> :. M <br /> Owner's Name .-----••----... .J-t2�-•-------•-- --------•- ---------------r-------- ---------Phone ®RI. 5� 7--2-•---- <br /> Address ...........•----- ---------•-------------City ----------------------------------------------------------•---•------------- <br /> Contractor's Name------------I................=.A7.1.64L.................... -----------:........License # ---•--7=........... Phone ----------------------- <br /> r <br /> Installation will serve: Residence❑Apartment House❑ Commercial C}Trailee Court 0 <br /> Motel ❑Other .................------................... <br /> Number of living units:___ ..__. Number of bedrooms ............Garbage Grinder _........... Lot Size ............................................. <br /> Water Supply: Public System and name .................................... ...................—.............,....................................:Private f] <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam•❑ Clay Loam <br /> i1 Hardpan❑ Adobe'❑ Fill Material ............ If yes,type..........------------------ U <br /> � I <br /> (Plot plan, showing of lot, location of system in relation to wells, buildings, etc. must be placed on r e side.) . 14 <br /> NEW INSTALLATION: (No s ' tank or seepage pit permitted if public sewer is available within 2 et,) <br /> r. ot. <br /> PACKAGE TREATMENT [ ] SEPTIC Size------------------------------------------------ ' id Depth ........................... <br /> Capacity --------------- -- Ty -................ Material............... No. Compartments ...................... <br /> Distance to nearest: Weli ................ ...............:. dation ____-.-_---- ------ Prop. line ---------....:...... <br /> LEACHING LINE [ ] No. of Lines ------------------__... Length of e---___....-_.:_._-- ------ Total Length ............................ <br /> V, Box ............ Type Filter M al ....................Dep 'Iter Material ---------------------------- <br /> 11 <br /> Distance to nearest: .............. Foundation .-..----.._.. Property. Line <br /> SE6AGE PIT De th ........._.. Diameter ---------------- Number _._..._..-._-.--_---_.-- Roc ad : Yes 0 No i❑ <br /> r Table Depth , .. j__...................-- -----.hock Size _, <br /> •: <br /> Distance to nearest: Well ......................... ........._Foundation . Prap. Line ._............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .........................................- -- Date ..............r---------?__-.._-__ <br /> Septic Tank (Specify.Requirements} ...................... <br /> Disposal Field (Specify t�Requirements) ............................... <br /> •------------------------------------------' -'-•"'-----'-'-------'._.._..__.._....._.._._..----'-'--'..........__._._........_.........._....__.._.. <br /> • <br /> -------------------- �.,---�. -"--�-...t__. ___•----.•_-_..-_�.._`___•-_•__.-._._.,.....-.-.t.........._...------_ ------ ....... ........-•---_-___.................- ..... <br /> (Draw existing and required odditioon on reverse sine) <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 taws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or liven- <br /> -sed agents signature certifies the following:. <br /> "F•certity that In the performance of the work for which this.permit Is issued, 1 shall not employaey person in such manner <br /> as to become sub', et tf'�W man's C pensation laws of Caljfornia." <br /> -- i/ <br /> s <br /> Signed. -------•-= r... Owner <br /> _ - <br /> By -------------------- -------- � title_...,,.................. <br /> (If Cfher than owner) <br /> FOR DEP TM ONLY <br /> APPLICATION ACCEPTED BY.................... ........-_ .. .. _ .-_..___. DATE •...fC�` d"I ._....•--------- <br /> BUILD1NG PERMIT, ISSUED;............----•........i.._-_ - - --•--------._.DATE-----------------------•---.-...._.-------- <br /> . --•-- --•----- ---- ....... . <br /> ADDITIONALCOMMENTS _... --------•---------•--- - --••------ =----------• -------------- ------- -------------------•------------•-----------•-------------•----- <br /> _ <br /> ...................... --••--._.. .... d --•-•. .- .---- ---•--- ---------------.----... . .......',_._.--••............................................................------..-• ... <br /> Final Inspection by. ..........----•_-•- --- <br /> __-------- --------•-•---------- •------•----••-----.._....-- '✓�I......Date %.7. ........._..._....... <br /> a SAN JOAQUIN LOCAL HEALTH DI iCT <br /> E.H. 9 l-'68 Rev. 5M <br />