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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> Permit Na.•I.Q__��S <br /> (Complete in Triplicate) <br /> ---- ----------------------------------------------------- Date issued/)J15-7 <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: <br /> JOB ADDRESS/LOCATIONf` � LI-----_---- _ - <br /> `5. ----- <br /> CENSUS TRACT --- <br /> L <br /> Owner's Name ✓_Y'_G� Q--------------------------------- <br /> Phone _../ __lam r�� <br /> Address ---- �� -1'7_Gcf �_A(-_.------------. City _ -Qy'`----------------------------------------- ----- <br /> Contractor's <br /> ---- <br /> .---- d <br /> Contractor sName ----___�__C'.�✓,!�?C3a-�------------------- ------------------------------------ <br /> License #_145,77'.2_3_410... Phone 97 J_9d`'`--7;! <br /> Installation will serve: Residence partment House❑ Commercial❑Trailer Court I❑ <br /> Motel [] Other -------------------------------------------- <br /> Number of living units: ------- Number of bedrooms Garbage Grinder/Yd_____ Lot Size ---------------------- <br /> Water Supply: Public System and name _________________________ _____________-. _ ------Private ❑ <br /> ------------------------------------------------------ - --- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam - Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type _-_____------------ ------- <br /> z of lot location of system in relation to wells, buildings, etc. must be placed on reverse side.) \,j <br /> (Plot plan, showing size Y <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 0 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth --------------------- Nl�l <br /> Y ------------------ <br /> Ca acitT e ---------------- -- Material---------------------- No. Compartments ------ ------- ------ <br /> PYP <br /> Distance to nearest: Well ------------------------------------Foundation ------_____------ Prop. Line ------------------.--- <br /> LEACHING LINE [ ] No. of Lines ----------------=------ Length of each line--.------------------------- Total Length ----------- ------_---_-- <br /> 'D' Box ------------ Type Filter Material ---------------Depth Filter Material -------------------------------------------- <br /> Distance to nearest: Well -----------------------y Foundation ------------------------ Property Line. -------------..--.------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ,i❑ <br /> Water Table Depth ------------------------------------ <br /> ------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------- ---- Prop. Line ---------------------- <br /> ti <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- --`----- __------- ----- Date --------------------- /--- --1 /' / <br /> Septic Tank (Specify Requirements) ------�lC�--,-- �<--- _ 'P�°�' ��' _61-e- (--1'Z4,1--- <br /> all <br /> Disposal Field (Specify Requirements) _1L'1�_�t�__ -- 'Y --- � � ' y'"`' <br /> --------------------- <br /> (Draw existing and required addition on reverse side) <br /> -------------------- - -- - ---- --- -------------------------.------- ------------------------------------------------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance w!h 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 /> "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 becom ubject to Workman's C pensatian laws of California." I <br /> Signed _ ___ Owner — -� <br /> BTitle --------------- --------------------------- ---------------------------- <br /> Y -- ----- <br /> (If othe than owner) <br /> OR .D PA:RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------- = --=-------------------------------------------------------------------------• DATE ----_7.7 fZ - -Z�---------- <br /> BUILDINGPERMIT ISSUED - ------ ------- '-------------------------------------------------------- ----------- -----------------DATE -------------------=--------`------------- <br /> ADDITIONALCOMMENTS --------------------------------- -------- -------------------------------------------------------------- --------------------------------•------------------ <br /> ------------- ---- -------------------------------------------------------------- ------------------ - <br /> A------------=---------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------- �- n- <br /> / ---------= ------ <br /> Final Inspection by: -------- ` Date __-- ------ [rte <br /> --C - --- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />