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FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit Na. hi <br /> ----------I-------- <br /> ------------- ----------- <br /> --------------------- This Permit Expires I Year From Date issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and <br /> install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATI N --- --- ---- --------- --------------CENSUS TRACT ----------_---------- <br /> Owner's Name ---------- / - <br /> Address ------------------- --------Phone,54le --- <br /> ------ --- -- -------- ---------------- --------- city ------ - - -- - -- -------------------- <br /> - -- ------------- <br /> Contractor's Name ------------ ------ ---!'z � <br /> License <br /> ---- Phone ---- -- --- <br /> 0 -------------- <br /> -- - ----- <br /> Installation will serve.- Re;ia;n—re 0-A—ppartmegn- <br /> :ou�se, _01111 I ❑Tra6fl_erCourt <br /> r ❑ <br /> _—Moteltl Other j_ <br /> - - ----- ----------- <br /> Number of living units:___ Number of bedrooms ____�>------WS�prbage G9rJ er ----- -----I Lo Size A570--------------- <br /> Water Supply: Public System and name ------ -------- ... .. <br /> -------- ------- -------------------- ----- ----Lz­-----------Private ❑ <br /> Character of soil to a depth of 3 feet: SandE] Silto� Clay E] peat E] Sandy!Loom -E] Clay Loam 0 <br /> Hardpan EJ AclobA-F �terial ------------ If Yes, type ---------------------------- <br /> �l�, M <br /> (Plot plan, showing size o'f-lot-location-of: system in relation tGweflS-,JbuiJdings,' etc. must be placed on reverse side.) <br /> ank <br /> NEW INSTALLATION: <br /> (No septic to seepage pit permitted if public-sewer-is-available within 200 feet,) <br /> PACKAGE TREATMENT SEPTICTANKfi.] Size_-_------- ----------------- ---- <br /> ---------- Liquid Depth -------------------------- <br /> CapacityType —--------I- No. Compartments ------ <br /> ----------- --------- I <br /> ---------- <br /> Distance tdi nearest.- Welli----------------------- Foundation -1-------------------- Prop. Line __.------------------- <br /> �< I t <br /> LEACHING LINE No. of Lines ---______±______ \_ -Length of each)line__________ --- Total Length ------------ ---------------- <br /> -D' Box\i�-------- Type Filter Material ---------------—_DeP­th-Filter Material - ------------------------ <br /> ------------------ <br /> Distance to nearest! Well ------------------------ Foundation! <br /> i ------------- ---------- Property Line _________.._______._.... <br /> SEEPAGE PIT Depth_f)_-------I Diameter ---------------- Number - ------------ ---------- Rock Filled Yes No <br /> 1 4- <br /> Water T,le Depth- ------------------------------------------------Rock Size ---- ---------------------- <br /> ea t <br /> D ----------.FoundationProp. Line -_----------_------ <br /> I stance to nearest Well ------------------------ ------------------- <br /> ------------- -------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------- _-1 <br /> D <br /> Septic Tank (Specify Requirements) --------- ----------------------------- ---- ----- --- ---------------I <br /> Disposal Field (Specify, Requirements) el <br /> - - - - ---- -------- ----------------- <br /> ----------------------------------------- ----------------------------- -------------------------------------------------- _1------------- ------------------------------------------ <br /> --------- - <br /> ---------- <br /> ------------------------------------------ ---------------------------- --------------------------I <br /> # ,{Draw <br /> -existing and required addition on r'ev7erse side) <br /> I I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> State <br /> f <br /> County Ordinances, St e Laws, and Rules and Regulations of.'the,Sah Joaquin Locat Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for whichthis peri-nit is issu�W,7_11).hdll.not employ any person in such manner <br /> laws of California."as to become subject to Workman's Compensation ti <br /> Signed ----------------------- - ! __ <br /> ---------- ------------------------------ Owner A <br /> By ------------------ ----- .......... ....r-----------ZZOA---------------------------- Title -------- - ------------------------------------------ <br /> (If other t owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTE <br /> BUILDINGPERMIT ISSUED - ---------------:-----------------------------------------------------------------------------------------DATE <br /> ADDITIONALCOMMENTS ---------------- ----------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------- <br /> ----------------------------- ---------- --------------/ -- ---------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------ <br /> ------------------------- ---------------- ------- -=---a ----------------------- --------------------------------------------------- ------- ------- <br /> Final Inspection ---- -- - -- - -------- <br /> -- ----------- <br /> --- -------- --------------- ----------------Date .... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1- Rev. 5M <br />