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FOR OFFICE US&-- <br /> APPLICATION FOR SANITATION PERMIT <br /> �E <br /> .................................................. <br /> Permit Na.(Complete In Triplicate) ( j/7� .. , <br /> ... .................................... ......... tills Permit Expires 1 Year Front Date Issued Date (sacred ...... <br /> Application Is hereby made to the,San Joaquin Local Health District for a permit to construct and install the work heren......._K <br /> described. This application is made In compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION �7 s f,f'/ ...................CENSUS TRACT .......................... <br /> Owner's Name . . . ...... .................................... ............Phone ................................ <br /> Address --�. ._.. .... .�.f . .''. �--� - ..._... City - u- ` ..........................��oo��._.... .... . :. .:.. <br /> 49. ..C.... .. <br /> �- ? . Phone . `4 " <br /> Contractor's Nama � = ......... ..................4icense ........__. -- <br /> Installation will serve: !((/// Residence®Apartment House fl Commercial❑Trailer Court 0 <br /> Motel ❑Other. ............. <br /> _Number of living units:-_----_- Number of bedrooms .-- :-.Garbage Grinder ----....---- Lot Size ............................................ <br /> Water Supply: Public System and,name .................�: --•- -'-------._._........._..................--•--•..................Private <br /> Character of soil to a depth of 3 feet: Sand 10 Silt® Clay [D Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> r Hardpan 0 Ado aterlal ............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 INSTALLATIONS (No septic tank or seepage pit permitted if public sewer is available within.200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size....... ........................................ Liquid Depth .........................- <br /> Capacity Type ... ......_. aterial----------- -----••--- No. Compartments ....................... <br /> • ....Foundation <br /> •. <br /> Distance !to nearest: Well ...���................. � ....IP............ Prop. Line-.4111W... <br /> '. LEACHING LINE [ ] No. of Lines -• ----------------- Length of each ilne..r�d.----............ Total- Length ..... fa .... <br /> 'D' Box .. Type Filter Material Depth Filter Material <br /> Distance to nearests Well ........................ Foundation _ ... Property' Line <br /> ' + ...........r....... <br /> . <br /> k SEEPAGE PIT [ ) Depth ................ Diameter ......._........ Number ... . Rock Filled Yes ❑ --Na <br /> Water Table Depth ------..........................................Rack Size --••--....... .................. <br /> 4-12 <br /> Distance'.to nearest: Well ..............Foundation ... Prop. tine .. ' <br /> E3 REPAIR/ADDITION(Prey. Sanitation Permit# ............................................ ate -.................................1 <br /> SepticTank iSpecify Requirements) ........................................... ............................................................................................... <br /> a Disposal Field (Specify Requirements) ................................................................................................................................... <br /> . <br /> r .................•-------.....------................. -•---•--------._....---....---.....-•----...._...............----..........-•---..............................._................................. <br /> ..................................._....._..................._..._.............................._...........-.......................................................:.................................... <br /> -' t (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the worts will be done In accordance with Sats Joaquin <br /> i County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Norrie owner or licen- <br /> sed agents signature certifies the fallowing: <br /> f "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 tatbecome subject to Workman's C mpensatlon laws of California" <br /> 1. Signed po <br /> ...... ....... ............................I................ Owner <br /> l/ <br /> By .........................................................................-............................. 7itle ......._....................................................... <br /> .. <br /> )If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .....:.. <br /> --• DATE ........ :L ..7 ................. <br /> BUILDING PERMIT ISSUED ....._... ...........I...- ........DATE <br /> ADDITIONAL COMMENTS ..........`..........-. .....:....:............. <br /> .....................................................' -............__.._._............-----....._.......................... ..... <br /> ................................................ f..........__......................-----........ --..............................._................_.....-- ....................................... <br /> ................ <br /> .. <br /> .................................................. . <br /> Date �P.._._ ....... <br /> Final Inspection by: .................... .. ......................................•----...----........................_...._.._.. ._....... . <br /> EH 13 2h l,b$ Rev. 5N SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 314 <br />