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FOR OFFICE USE- N11,APPLICATION FOR SANITATION PERMIT <br /> 3 <br /> Perm it No. <br /> -`f(s <br /> (Complete in Triplicate) <br /> ------------------ p <br /> Date Issued -401_G�- -. <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/LOCATION . L _,-lie�� .f // j`----------------------------------CENSUS TRACT --------------•----------- <br /> PhF__ <br /> Owner's Name ---��.�--fJ-�------ <br /> -- '�-�,�,�.�`------------ -------------------------- --------------- ----------"-`------ --- - one �-- ------ --------- --------- <br /> 1, Cit ;- <br /> Address - -��'��-----�----��.1�..�J---- ---------------- ------------- Y��.�T'------------------- ---------------- --------•--------•-- <br /> Contractor s Name - --- - - <br /> ---------.License # 477978 mw--- Phone4yy- <br /> Installation will serve: Residence P -Apartment House'❑ Commercial :[]Trailer Court '❑ <br /> Motel ❑ Other -------------------------------------------- t <br /> r <br /> Number of living units:--_ L_ Number of bedrooms -----Garba_ge Grinder Lot Size ------------- <br /> Water <br /> ------------- <br /> Water Supply: Public System and name -------------------------- ----------------------- --------------•------•-------------------------------------Private ❑ <br /> i Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay.Loam ;❑ <br /> f } t- -Hardpan ❑ Adobe Material ------------ If yes,type ---------------------------- <br /> I <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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ------'-------------- Liquid Depth --------------- •-------- <br /> PACKAGE TREATMENT SEPTIC TANK [ Size------------------ <br /> capacity <br /> ------------------ TYPe ____ _____------- Materia ----- -------- <br /> V <br /> Distance to nearest: Well ------------------------------------Foundation --- ------------------ Prop. Line ---------------------- <br /> -11 <br /> LEeG LINELines ----" Length of each line---------------------------- Total Length ------.-------------.------- <br /> No. <br /> LE GLINT: [ } Bo ---------- ------__---- ------- Type Filter Material ------------== -Depth :Filter Material -----------------.- <br /> Distande to nearest: Well ------------------------ Fcur4dtion ---------------------Property Line ---------•-------•------ <br /> ` SEEPAGE PIT [ ] Depth ` ------------------- Diameter ---------------- Number ---------------------------- Rack Filled Yes ❑ Na 0Water Table Depth -----------------Rock Size ------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date -------------------�--/---�------_--- <br /> - <br /> Septic Tank (Specify Requirements) -------- ------------------------------- ---------- ----------------------------•---- :--t-:------}- <br /> ---------..------------------------- <br /> ------------------------------•----------- <br /> Dis osal Field ISpecify{SpecifyRequirements) <br /> ,�'�' ----- ----- <br /> l U. p ---------------=------- --------------------------------------w----------------------- <br /> ----�-------660 -----°hD} ---------------------- ------------------------------------------------------------------------------------------------------------- <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 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 become ub!WtWor man's Compensation laws of California." <br /> Sigd -_-_ne - Owner <br /> ----- <br /> -------------------------------- Title ---- ------------ ------------------ ----------------- ------ <br /> (If other than owner) <br /> y FOR DEPARTMENT U5E ONLY <br /> ( APPLICATION ACCEPTED BY -- _ ____ --- <br /> --- - --- - --------------- -------------------------------------------------- DATE ---- -'� .. ----------------- <br /> BUILDING PERMIT ISSUED -- -------- --- - ---------------------- -------DATE ------------------------------------------- <br /> ---------------------------------------------- - - <br /> ADDITIONAL COMMENTS ------1 i--------------- -------------------------- ------------------------ <br /> t ----------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ <br /> -------- <br /> --------------------------------- ----- ---- --- - ,, ------- <br /> Final Inspection by: t <br /> '''j ------- ------------------ ------------------------- Date �� <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'B8 Rev. 5M• <br />