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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------•---------------- - <br /> (Complefe' <br /> as <br /> in Triplicate) Permit No: <br /> ---I--- Date Issued ___ <br /> --------------------------------------------------- ----- This Permit Expires 1 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 <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: f <br /> �/7.� �s/i�.d�°L-�a�+e►/' L7�s�AG?"'4 e�'��SeJ.✓(6+4�cs1—,... ' .. <br /> JOB ADDRESS/LOCATION em---rte!---------------------- -------------- --CENSUS TRACT ------------------------ <br /> Owner's Name El _.. 'sf I l__ ?��r. r __ +a 4• _ -------------Phone--_------------_----------- <br /> ---------- <br /> Address _flf.2t¢ - arwr� _ _ -----. city s��eG� ---"---------------------- <br /> ----- - ----- -------•-•--------- <br /> Contractor's Name <br /> -------- -------License # ------------------------ Phone !_f_a ! 4 <br /> Installation will serve: Residence ❑Apartment House-[:] Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -a-04, /-r <br /> g y Garbage Grinder V'�"" Loi Size" � P` �s__ <br /> Water Supply. Public System and name _____________ _ ___ _ <br /> --------------------- ---- vat <br /> um ------------ <br /> Number o living units:_____- Number of bedrooms e <br /> Character of soil to a depth of 3 feet: Sand Silt'` <br /> p ❑ fl Gay ❑ PeatX JSandy Loam ❑ ''" Clay roti ❑ 1 <br /> Hardpan ❑ Adobe ❑ Fill Material -------'--- If yes, type ---------------------------- f <br /> (Plot plan, showing size of'lot, location of system in relation- o wells, buildings, etcf�must be placed on reverse side.) <br /> NEW INSTALLATION: (No.septic tank or seepage pit permitted if.public sewer is available within 200 feet,) t \ <br /> PACKAGE TREATMENT [ ] ., SEPTIC TANK[ ) Size_-! _?�_ * ___- Liquid Depth <br /> _ ' <br /> CapacitySQ_Q___-- Type __----- r � --- itJl � No. Compartments ------------ <br /> Material <br /> Distance to nearest: Well ---- - ____________________Foundation E.�'� _ l <br /> Prop. Line <br /> LEACHING LINE - No. of Lines --- r <br /> --t 1-_e___ ___+ Length of each line_ _ QX,Qe7Total Length <br /> ,fi�N ¢ jD' Box __ yp Filter Material _A__.X1�_Depth Filter�aterial ___. ____________ ______ <br /> 3®`x QQ ` ` , ... i I ms`s i._�.....__ .�., I <br /> (w:.- ..�,.� Distance to nearest: Well ----- ----------- Foundation - 0- ------- Property Line _ ----------------- <br /> SEEPAGE,PIT­(-I . ,Depth t-------------------- Diameter ---------------- Number ----------- --- -_-- Rock Filled Yes [:1No C]�. <br /> - .Water Table Depth Rock <br /> s Distance to nearest: Well ----------------------------------------Foundation -------- ----------- Prop. Line ............ ..... <br /> REPAIR/ADDITION(Previ Sanitation Permit# -------- ----------------- ----------------- Date ----.-------__---- <br /> fSeptic 'ank-(Specify Requirements) -------------------------------------------------------------------------•-------------- <br /> tDisposal Field (Specify Requirements) --------------------------------------------- <br /> ----------------=----------------=------- <br /> --- - - ----------------------------------------------------------------------------------------- <br /> i <br /> '--------------------- '----- I------- <br /> ------ ----------------------------------------------------------------------------------------- <br /> f (Draw existing and required addition on reverse side) <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: <br /> Ail ce'tify�that in the performance of the work for which this permit is issued, .t shall not employ any person in such manner <br /> as to becom bject to Workman's Compensation laws of California." <br /> j � r <br /> Signed <br /> i I ' ----_-•_-- Owner <br /> BYE -R - - - - ------------------------ Title <br /> --------------------------------------------- <br /> t t of er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.._� cr__ 4 <br /> ,' DATEZ.2--- ------------ ------ <br /> DING PERMIT ISSUED -------------------DATE ------------------- <br /> ADDITIONAL COMMENTS --- <br /> ------- <br /> - F` <br /> - ---------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------- <br /> ----------------------------- ------------ <br /> Final `n _ ate <br /> --- ------------------------- <br /> Finall b ----- 1 <br /> nspection y•' .-.� - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />.�_ E. H. 9 1-'b8 Rev. 5M <br />