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FOR OFFICE USEt APPLICATION FOR SANITATION PERMIT <br />..................................................... (Complete in Triplicate) Permit No. 2. .. <br /> .. <br />..........................................I........... - = Date lasued .G x.:76 <br /> ....................................... .... This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein F <br /> described. This application Is made in compliance with County.Ordinance No/549 and existing Rules and Regulationst <br /> JOB ADDRESS/LOCATI �? `. .........E...... .................r. .... r CENSUS TRACT ........................... <br /> Owner's Name ..... ... ... ........ ............. . ......... Phone` ��.... ���.............. # <br /> Address ................ ._. ...... ....City .... ....__......._.�• ... _ <br /> Contractor's Name ............: ..�. .....e.. ............license } .: ..... Phone.. ,� �...... <br /> Installation-will-.serve:.• Residence4-Apartment-House(3,Commercial.❑Traller Court...❑ _ <br /> Motel ❑Other............................................ � r <br /> Number of living unitsi_..�. Number of bedrooms .........__.Garbage Grind Lot Size •-�►.4�__C..%...........................� <br /> Water Supply, Public System and name ------ . `"-, � � = -�: . ...:....:...............Private❑ i <br /> f soil to a depth of 3 feet: Sand 0 Silt❑ Clay Q Peat❑ Sandy Loam ❑ Clay Loam ❑ uJ` <br /> Character o :.� <br /> �-- Hardpan.p---Adobe%_fIII.A"rla! ..............If yes,Type .......... ............ <br /> {Plot plan, showing size of lot; loc'ationl,O_V'system In relation to wells, buildings,•.etc. must be plated an reverse side. <br /> NEW INSTALLATION: INo septic tank or'seepage pit permitted If public sewer is avalloble within 204 feet,► <br /> PACKAGE TREATMENT I ) SEPTIC TANK ` "" _Size........................................s Liquid Depth <br /> Capacity --•-•............... Type s.................`. Material........---........... No. Compartments ........ ... <br /> ...... • <br /> Distance to nearest. Well ._ ..............Foundation .... Prop. line <br /> LEACHING LINE ( � No. of dines .- ._ .. _' :. Length of each lino*- -.._ Total length ........................ x <br /> 'D' Box ........... Type Filter Material'. ..............Depth Filter Material ........................................... <br /> . , Distance to nearest: ........................:........t. Foundation ........................ Property Line ........................ <br /> a •, <br /> SEEPAGE PIT ( } Depth Diameter Number .. Rock Filled Yes ❑ No ' <br /> Water Table Depth ................................................Rock Size ...• .... ..... <br /> Distance to._neara tr Well ._.._ ........-----...¥ <br /> .....:................Foundation_... Prop. Line .................... <br /> REPAIR/ADDITION(Prov. Sanitation Permit j�.... . ......:......... D e,....... ... ... .) <br /> Septic Tank {Specify Requirements) ...........Cti. ' .. ........ .e .•`-�:��?�. .-. ....._._ .......... <br /> Disposal Field (Specify Requirements) . .�. .� K... . _ r .... . ... ........'....--.........--.... .................... <br /> ....................... .'. tf ........._...... .... ...-» <br /> ................. <br /> ..................I................ ---................... .................. .----.....q............_............. .................................................. <br /> Draw existingand required addition an reverse side) i <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 Rules and Reguldtions of the San Joaquin local Health District. Home owner or Iicam <br /> sed agents signature certifies the following: <br /> ".I certify that in the performance of the work for which this permit is Issued. 1 siial!not employ any Iverson In such manner <br /> as to become subject to Workman's Compensation laws of California-" <br /> Signed ... ...... ..... a ........................................... Owner , ' <br /> By ................ ......... ..... . ... . ........................................... Sitle ..... " ...................................... .......... <br /> lif h r-than owner) <br /> 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .......... .. DATE ...... .. -..3. <br /> BUILDING PERMIT ISSUED .........................................DATE ....................... <br /> ............... <br /> ADDITIONAL COMMENTS <br /> :_........................................................... <br /> �.— ................ <br /> •-----------------•-...................................................::... .:. ------........................................................-.... <br /> ................................._...-•----............................. ........`.....:............... <br /> •. <br /> ...........................•.......................:.. ... ................. :...... <br /> 4 <br /> 1. <br /> ....... ...- ..�.. Date .... zw� <br /> l inspection by -. ... . . ......._::�.��+`�1p. . .,..... -. -..-•-••.......................Mi 13 2h 1-6f1 Nov. 5m SAN OAQUIN LOCAL HEAL DI5 R <br /> j . <br /> �1 <br /> ' f <br />