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FOR OFFICE USE: \ <br /> APPLICATION FOR SANITATION PERMIT <br /> .................................................I k <br /> iPermit No. <br /> (Complete in Triplicate) <br /> .. . <br /> .............. <br /> ............. .. .. .. .............I........-. This permit Expires 1 Year From Date Issued <br /> 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 <br /> eeJwith County Ordinance <br /> ®No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO "TIONc �. . . �yf � `'�'" � r.........................CENSUS TRACT .._................._ ..Owner's Name r . .... �..................................................................Phone . ................................ <br /> fAddress ...... ....;w)— Q..7 .. ... :. dry,. ...:....City ... . e ..:.....:..: ....... . <br /> Contractor's Name .._.. ,.c! — Lice # .1� :.y�hone .............. ............. <br /> Installation will serve: Residence❑Apartment House 0 Commercial Troller Court 0 <br /> ., Motel C]Other....... . ............... _ <br /> Number of living units:—.. .... ... Number of bedrooms :"..Garbage Grinder Lot Size ��--� <br /> Water Supply:•Public System:and name.....:.............................:........._...-•----..._..------..-•-................... .........---_..._Private , <br /> Character bf soil to a depth of 3 feet: Sand n .Silt(] Clay'❑ "`Peat j] Sandy loam 0 Gay Loam <br /> Hardpan❑. Adobe[] F1i1 Material ............If yes,type--------................... <br /> F (Plot. plan, showing size of..lot, location of..sw7ge <br /> in relation.to wells, buildings, etc. must be placed- on reverse side.) <br /> ( NEW INSTALLATION: (No septic tank or see pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size 1 .. r S f <br /> � �•---t'�-��-----x.................•----.. Liquid Depth .4......._...1. .. <br /> Capacity . ... # Typ '. Material-_.L.�4.7...-�...... No. Compartments ......o <br /> /Distance to near st: Well ................Foundation ..:.�::._•.....••.... <br /> Elf <br /> ................•----- <br /> LEACHING LI'Nt No.`of Lines J.......::::`. Length of each line....�d � Total Length ..5 ................... <br /> N <br /> 'D' Box ............. Type Filter Material'....-52P.-.....Depth Filter Material ....11.......... - ' .... <br /> Distance to nearest; Well ...�..: Foundation ....:��f..::..' .- Property Ling '~. r......... ' <br /> -- .. <br /> 1 <br /> SEEPAGE PIT- De�th c .___.__1• Diameter a ' <br /> [ p ---- --- .5`-•- •-,��•----'Number ..........., .............. Ronk Filled Yes No � <br /> Water fable Depth. ..........I..A" .-.........Rock Size ./- . .,et' . . ..... <br /> ........ ..... . <br /> Distance to nearest: Well ...._..... .Q.>� Foundation p. <br /> ................ --•-•._...._..._ Pro Lira ... ............._.._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .............•.................... <br /> J <br /> SepticTank (Specify Requirements) ............: ..................•-.......... .•----.................__......._............_._........_...._........_._...... <br /> Disposal Field (Specify Requirements) --------------------------------------------------------------------------•----- •--•------- <br /> ...:..............................•--•--.....---•-............•-•-•-._..........••-••-............----.....------•------••••-...--•--...:_.............._..............._..:............I.............._. <br /> ................------------------••---- ...................................•.....................................-.................................................._......_................................... <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 DWct. }come owner or [icon- <br /> sad agents signature certifies the foliowingr <br /> "I:certify that in the performance of the work for which this permit Ii Issued, I shall not employ any person in such manner <br /> as to become subject to Wor � n Compensatlon IaW3 f California." <br /> Signed...:::.._....................:. ._.::_._: :..... - - �t............. Owner <br /> By .........:......:.j:......:.......... --......_... isp_ Title ----. !1s .��. ......----•-........................ <br /> If other than owner) Q <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.. _. . _._.. ......:................................ DATE.� .........J.:J-.j•�_....._...... <br /> -• <br /> BUILDING PERMIT ISSUED —................:. DATE ....._...._........... <br /> ....-----••.....................•..._.:.............................••--•....... ...........•..... <br /> ADDITIONAL COMMENTS .........:..........................................................' <br /> .......................................•--------•-•----.._...-.._.............----.----••-••-•-•---------- .................................................._.......--...•... ........................ <br /> Finol.lns..ection.......: .._. . ......... <br /> ...-•............... •-••--...................-•-•-----.................••............. ........ <br /> ........_... . <br /> Ay. �* ................................................................ ...........,.._Date .'.. ". ............... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> E.H.13 241.•68 Rev, 5M 7/72 3 M <br />