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FQrR OFfiCE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..::::....:.......................:.................. <br /> Permit No: � <br /> 4 <br /> (Complete In Triplicate) ~....... <br /> ..__.....A..-�...__,..................................... <br /> �. Date lssuec9,�-aa: . <br /> .....................................................1:.....__........ This Permit Expires i Year From Date Issued <br /> Application ishereby 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 /> 6 n � <br /> J013 ADDRESS/LOCATION ... . .. _�?...... :---..� 1/�X ...................................CENSUS TRACT`__....._.._.._...:..... i <br /> .Ownera Name ..................... -- . -•---••...._... ........ .Phone .�, .�� ......... <br /> 'Address ... � ........................................ City ... ............. ..................... .._.......... <br /> (' ... <br /> Contractor's Name :................... : . ..._. ....$__ !� Z- ........License .13... Phone <br /> Installation will serve: , Residence Apartment House Commercial ❑Trailer 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 <br />. <br /> .,Character of soil too depth of 3 feet: Sand'❑ Silt❑ Clay., ❑.. Peat❑ Sandy Loam _ Clay-Loom �.:. .- <br /> Hardpan ❑ Adobe 0 Fill Material ............ If yes, type � <br /> (Plot plan, showing size of tot, location of system in relation to wells, buildings, etc. must 'be placed on reverse side.) <br /> NEW INSTALLATION:. -.1(No septic tank or seepage :pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT° [�} ' SEPTIC�TyA�NK Si e...---.a..__.X-...r1........................ Liquid Depth ...S_Y,.......... � <br /> l RC1 ... V x <br /> Capacity f: _ _----- Type -- . ...... Material...C�_ r.. No. Compartnnents ...:L:............ <br /> Distance to n crest: Well ...Foundation .../Q.............. Prop. <br /> LEACHING LINE No.of lines --------.3....._- ;Length of each line_...........70... ... a Length .. . ........... <br /> Total eng ... <br /> 'D' Box ...IL . Type Filter Material . ... ...... . ......Depth Filter Material ...... .......................... <br /> Distance to nearest:.Well ... Foundation ._:.-1.-{�..�?� ..... Property Line ...4............... <br /> SEEPAGE PIT [ ] 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 ...................................11 <br /> Septic Tank (Specify Requirements] <br /> L <br /> Disposal Field (Specify Requirements) <br /> (Draw existing and required addition on reverse side) <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 Regulations of the-San Joaquin Local Health District. Home owner or licew <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 .......�44 <br /> ---...---- -- �--_-.._..._ Owner <br /> BY ............. -- Title ._.....__... ...................... <br /> n ownerl <br /> FOR DEPARTMENTUSE ONLY <br /> AMI,CATION ACCEPTED BY ...... ........ <br /> _.....__-• � ♦Z <br /> -- -••.............. . .•-------------•--------------••---... DATE ...._..----........_....-•-------...__..... <br /> BUILDING PERMIT ISSUED .................... ----------------------•------. ---.,::.. ---------------DATE ----------- .............................-. <br /> ADDITIONALCOMMENTS ....................................................................................................................................... <br /> ...... <br /> ............................. .......................................... . .......••-----------------------•---•--•--.-.-.-_.-.-.-.-_-..-.-.•.•-..-.-.-.-.-.-.......-.-.-_-.-_-.-.-.-.-.-.--...-.-.--.._.-.-.-.-_-........_...........^.........`.......-.•---.....-..--..-. <br /> .................... ------- ------ <br /> � <br /> ........ ...... <br /> . Date a,frnal Inspection by l - .. l7... ........... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> __E -13 241_ <br />