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FOR--OFFICE USE: <br /> -------------- -- ------ APPLICATION FOR SANITATION PERMIT <br /> I---- ---"---- <br /> --------- (Complete in Triplicate) Permit No: _rte_ �_-/�D_" <br /> ----------- <br /> r -------------- - This permit Expires 1 Year From,bale Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein <br /> described. This application is made in compliance witWCounty Ordinance No. 549 and existing Rules and Regu tions: <br /> �y-�� <br /> JOB ADDRESS/LOCATION zJ77// �C !d�✓fd,� I y I <br /> - --------------------- -- -- �'m�v- , <br /> • '��T ,--.-- cENsus TRACT - <br /> Owner's Name _Y�+/l�it_ Ey �71�1Q = i •-- --- <br /> - Phone <br /> Address ------ --..�.��Z1--- -�a,4�• } ° # ---- -- --- ----f�--��- <br /> i ---- -------- --------------- -------- - Cityr�'�(= /1/ <br /> Contractor's Name - --- t <br /> �!^ ------------------ - 'License ---------------------------- <br /> Residence �.� <br /> Installation will serve: f ` - Phone <br /> p artment House-0 Commercial:OTraiier Court ;❑ <br /> Mote! El Other -- --- ----_ _-__ r <br /> 1 ( <br /> Number of living units:_.. ------ Number of bedroom � f <br /> � 1 t '. <br /> 1 --_ .Garbage Grinder 1 L'ot Size -�"--_ _ <br /> Water Supply: Public System and name _.___ "._ <br /> --------- ------------------- ---- t <br /> Character of soil to a depth of 3 feet: Sand Private [ <br /> (Silt❑ I Clay ❑ Peat.O Sandy Loam ❑ Clay Loam .❑ <br /> Hardpan ._ .� r e. :r r <br /> P ❑ Adobe.[)_. Fill Material l_V-Q -- If Yes, t a _._._._"-_"""__-- <br /> (Plot plan, showing size of lot, location of system `in' relation to wells, buildi,ngs,j tc must be placed on reverse side.) p� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,). N <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[L]� �/ ` ,,11 <br /> Size. -X__! --X_;7` �� <br /> -- --------s- Liquid Depth <br /> Ca ocit - ----- <br /> p Y /�f1---_-_ -_ Type,--?��'__ Materials;'c�i1#�FT.�" 1�� <br /> No. Compartments, ___"__ " <br /> Distance to nearest: Well ' <br /> Length <br /> Foundation �C��-- V--:5 r..t <br /> LEACHING LINE Prop. Line -------------------- <br /> [1}r No. of,Lines gth of each 4 Y <br /> - it <br /> 'D' Box .�_-_ T <br /> Mt ch line_-_- -------_ } iota! Length <br /> ype Filter Material 00"r-------- Filter Material /_. __`!-"_'-__"� . <br /> Distance to nearest: Well _ r f <br /> ��-- -------.--"" Foundation <br /> SEEPAGE PIT DepthI f ---- - --- Property Line ----- <br /> ---------- Diameters Number. <br /> •--_-. Rock Filled Yes ❑ No <br /> Water Table Deprh !-"_ S I , <br /> `.Rock Size ---------- <br /> Distance to nearest: Well --------_{__ -- --------"_- �.i" _ <br /> t> <br /> 77 � Founda#ion --- Prop. Line ------------ <br /> - �..- <br /> REPAIR/ADDITION[Pre~. SanitationPerm t_# _____ ______P_._ ,___"- _ pate_____________ ) "x <br /> . + _ <br /> t <br /> Septic Tank (Specify Requirements) " -------- _�,. _ <br /> ` ------- ----------------------- -- - <br /> Disposal Field (Specify Requirements) '�._ _" _ , - ------ <br /> ��'j , ; <br /> -- ----------------- ---------------------------- ---------------- <br /> ------- -------------------------------------------------- f <br /> __ ______ ________ i ., ,4 i. '. . ... <br /> r _ - <br /> (Draw existingand required addition =4+ verse side) t.._ <br /> I hereby certify that I haveapp _ _ <br /> County Ordinances, State Laws,pand'Rules and,Regulationscation and tof the San J aquin J0 <br /> e 'work will be oHealth Di ne in accordance with San Joat{uin <br /> sed agents_signature certifies the fall wing: ;,`. District. Home owner or Ricen- <br />--......! g:- A i <br /> "1 certify that in-theperformance of"the to workfor <br /> Signed for which this permit is issued, I shall not em <br /> as to become subject to Workman's Compensation laws of California."• P y an Y person in such manner <br /> � . <br /> 4�- --- .,,::- <br /> ----------------- <br /> ------------------------ <br /> By <br /> Owner h i <br /> (If other than Iowner) <br /> - -------------- ---- -------------------- Title • <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 8Y ` t�.-O�__-___""- ( <br /> BUILDING PERMIT ISSUED ------ - ------------------ ------ --------- DATE .... ' � ` t <br /> r <br /> ADDITIONAL COMMENTS ....... --- ---------- _ = ------ --DATE <br /> ' { <br /> ---------------------------- --- <br /> ---- ----------------------------- ------------ <br /> ------------ <br /> - --------- <br /> ------- -=- -- ------ <br /> Final -------------------------- ----------------- <br /> Fina! Inspection b ----- - -- " <br /> b�------------------------------------ -- +� <br /> - --- -- - ------Date __J'.��:�- --- --�- --- <br /> "" —SAN JOAQUIN .LOCAL,HEALTH~DISTRICT_. <br /> 9 1-'6$ Rev. 5M <br />