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A. <br /> FOR OFFICE'USE?-. - <br /> APPLICATION-FOR SANITATION PERMIT <br /> --------------------------- ----------- Permit No. <br /> (Complete in Triplicate) <br /> ------------ ------------ -------------------------------- <br /> -----------------_ I A This Permit Expires ] Year From Date Issued Date Issued <br /> ----- ------:------------:--------------- <br /> Application is hereby made to the San Joaquin Local Health District for <br /> .0it to construct and install the work herei' <br /> 549 and exlsti%ules and Regulations: <br /> described. This application is made in comp.Lp7ne��h 2,0 <br /> f iv <br /> f 41,7 <br /> JOB ADDRESS/LOCA- ON fi �---P _. _�_ �I T 64.fi , <br /> ------- --------r --i ___ - __ _ _ -----CENSU!; 'I --------------I------------ <br /> --- --- -- ---------- ------- ------------- <br /> . I - I - ----------- <br /> -- -- -------------- ------ <br /> Owner's Name ------------------- -- -----Phone.------- ---------------­-------- <br /> ------ ------ <br /> Address ---------- ------- _4P--------- -i�_ , City --------------------------- <br /> -->-V; I - -7 --;59 . <br /> Contractor's Name ------------------- ------- -----------------------License # hone e., I <br /> -- ------------ <br /> Installation will serve. Residence partment House 0 Commercial f7railer Court F] <br /> Motel F�Other ----- ------------------------------ <br /> ---------- <br /> Number of living units ----- Number of bedrooms-��?---,..Garbage Grinder AICs____ Lot Size <br /> Water Supply: Public System and name ------------------------------------------------ r/ <br /> -------------- ---------------------------- ---------------Private <br /> Character of soil to a depth of 3 feet. Sand 7 Silt Clay E] Peat E] Sandy Loam ,E] Clay,Loam <br /> Hardpan ❑ Adoben--5, I�Material If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT SEPTIC-TANK! ize Depth ------------ <br /> ------------- Liquid <br /> �y ----------- -;;, <br /> Capacity TYF)v7���L-aMaterial-(!02PI<--�t��o. Compartments ­........ <br /> Distance to; nearest: Well -------4-0-------------------F66-ndation --------- Prop. Line ......... <br /> ------ Total Length <br /> LEACHING LINE No. of Lines --------- Length of each line.-) <br /> 'D' Box 4-%-- <br /> Type Filter Material _)11_Zt------------Depth Filter Material -------------------------- <br /> I----------- I - <br /> Distance nearest: W611 Foundation 4p------------- Property Line. ........... <br /> SEEPAGE PIT [ ---- fj---- Number ------ -- - RocY <br /> lDe <br /> y Diameter -_ -- ------ --- k Filled s 0 ff �.P <br /> Water Table' Depth ----------------1--6------------------------Rock Size JJ�__-J------ <br /> - <br /> Distance to nearest: Well -------/_0__d----------------------F66ndation_1,4_---------- Prop. Line 1.- ------ <br /> REPAIR/ADDITION(Prev, Sanitation Permit# --------- ---------------------------------- Date --------------------- <br /> Septic Tank (Specify Requirements} ----------------------------------------------------------------- --------------I------------------------ --------------- <br /> Disposal Field (Specify Requirements) ---------------------------------' :------------ ------------------------------------------------------------5-. <br /> --------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- <br /> ------------- --- ---------------------- -------- ------------------------------------------ <br /> ---- -------------------------------------------------- ------------------------------------------- <br /> (Diaw existing side)-pr)4 �tqyired addition on reverse <br /> 7% ---- - 4-�- <br /> 1 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 licen- <br /> sed agents signature certifies the following- a <br /> 1 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 --------------- ----- ------------------------- - Owner <br /> By --------- -------------- --- ---- -------- Title ------0-Li---- —---------------- ---- ---------------- <br /> ------ ---- <br /> (if oth)t an�awner) FOR DEPAR-TMENT USE ONLY <br /> APPLICATION ACCEPTED BY-1 ,"- <br /> ----- - - -- -- - - ----------------------------------------------- DATE.- ---- <br /> ------------------------=--------------DATE ---------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------- ----- ---------------- -------- ---- -- ------ - ► <br /> ADDITIONALCOMMENTS -----------------------------------------------------------------------------------------------------------------------------------m 6 1 <br /> ------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -- -------------- -- ------------------------------------------------------------------------------------------------------------------ ----------------- <br /> t <br /> ------- ---- - - -- -- - ----- ---- - <br /> - <br /> FinalInspection by: -- ----------------------------------------------------------------------------- ----I. <br /> ---------- -:7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M, <br />