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FOR OFFICE USE:-—, <br /> I.o �1 - , APPLICATION FOR SANITATION -PERMIT <br /> n va_&q - "_-�?-`' " -— .,-i I <br /> ----- - ---------I-----------r-------- Permit No.,_6_�'_A� <br /> (Complete in Triplicate) ------------- <br /> This Permit Expires I Year From Date Issued Date Issued <br /> -------- ------------------------------------------------ <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 cArnploce with Count din?nce No. 549 and existing Rules and Regulations: <br /> -0 <br /> JOB ADDRESS/LOCATIC)q -A",Y__ 449�,V. -CENSUS TRACT --------------_---------- <br /> 'Owner's Name -------avp_qs. -----------------------------------------------------------------Phone 11 ,-- <br /> 2 ---- -------------------- <br /> lAddress - 3,3-15------,1%`'"_h-W. O A"_0-------------------------------------------------- ---- city _01^?2-G -:---- <br /> 'Contractor's <br /> ------------------------------------- <br /> 'Contractor s Name --------m------------------------ License # /7713----- Phone --------------- <br /> Installation will serve-. Residence Erl Apartment House,E] Commercial E]Trailer Court ❑ <br /> Motel E]Other ------------------------------------------ <br /> IlNumber of living units:.-/-------- Number of bedrooms __�/------Garbage Grinder I_Vd---- Lot Size 4F__1_!57CA5e— ----------------- <br /> Water Supply: Public System and name ---------------------------------- -----------------------------------------------------------------------------Private <br /> ]Character of soil to a depth of 3 feet: Sand Silt El Clay E] Peat E] Sandy Loom E] Clay Loam <br /> Hardpan ❑ Adobe [] Fill Material ------------ If yes, type ------- --------------------- <br /> (Plot plan, showing size of lot,. location of system in relation to wells, buildings, etc. must be placed on reverse -side.) <br /> NEW INSTALLATION; <br /> (No'septic tank or seepage pit permitted if public sewer is available within 200 feet,]I r / <br /> PACKAGE TREATMENT SEPTIC TANK Size--d A/------------ Liquid Depth _41- ---------- <br /> Capacity Type� MateriaIs9&e7ePK7'/_77 No. Compartments 1_Z------------ <br /> Di'stance to nearest: Well --------------------------- Foundation ------------- Prop. Line -------- <br /> LEACHING LINE [A No. of Lines ---13---------------- Length of each line__-- />---- Total Length <br /> �'' . -------`' <br /> 'D' Box Type Filter Material -----Depth Filter Material --- ��__-------------------------- <br /> Distance to nearest: Well _Tj��................. Foundation -40----------------- Property Line, --------------------- <br /> ,SEEPAGE PIT Depth ------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well -------- ------------------------------Foundation -------------------- Prop. Line ------------- <br /> REPAIR/ADDITION(Prev. Sanitation;Permit# --------------------------------------------- D I ate ----------------.--.------------ -) <br /> Tank (Specify Requirements, ------------------ ---------------------------------------7------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirerh.ents) --------------------------------------------------------- ------I--------------------------------------------------------------------- <br /> ------------­--------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- ---------- <br /> -- ------------------------------- ------------ --- - -1--- ----- - - --- - - - ------------------------------------------------------------------------------- <br /> --------------------- <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 Son Joaquin <br /> County Ordinances, State Laws, an;d 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 /> i"as to become subject to Work I <br /> b 1 r. an's <br /> Compensation laws of California." <br /> Owner <br /> igned .... -- -- ---- <br /> By -------------------------------------------------------------------------------------------------------- Title ----------------- --------_------------------ ----------- ------------ <br /> (If other than owner) <br /> J FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- ---------------- ------------------------------------ DATE ---- ---------- <br /> BUILDINGPERMIT ISSUED ------------- ----------------------------------------- -- ----------------------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS --------------- ------------------------------------------- ------------------- ---------------------------------------------------------------------------- <br /> -------------------------------------------------------------- --------------- ------------------------------------------------------------------------------------------------------------ --------------- <br /> ---------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - ------------ <br /> ----------------------------------- ---------------------------- <br /> Final Inspection by. Date ---- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />