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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ..............I........ ....._.._._.... <br /> ........_ Permit No. ...��.,�...._....... <br /> (Complete in Triplicate) p� 4 <br /> y <br /> Date Issued ...d...'.�.:..7. i <br /> This Permit Expires 1 Year From Date issued j <br /> Application is hereby mode to the San Joaquin Local Health District for a permit to construct and install the work herein 1 <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIONf� --.•..fes..... Of'Q ,.:.` -..;....:CENSUS�TRACT .... �� <br /> O /7 ...1 : ..- .,/ . . -/Ylc"/' ........................................ � .... Phoneme , a� <br /> Owner's Name ... � <br /> Address . � �._.._.. .��� , '.�•- ......................... City ._5 �............. <br /> ...._._.__ <br /> 'G <br /> S` ._... . ..-- <br /> / Phone — ` <br /> Contractor's Name .. . . <br /> Installation will serve_: Residence Q Apartment Hauser] Commercial QTrailer Court 0 <br /> Motel ❑Other .............:........ <br /> ..... ..—:::.—_::.:: --_ <br /> Number of living units:-.L.... Number of bedrooms .,......Garbage Grinder -IYQ Lot.Size, , -1 ---••• <br /> Private <br /> Water Supply: Public System and name ' .....::::::.::.:.::__...._:__......---•----• ----..-_-.------ ..._.... Q. <br /> Character of soil to a depth of 3 feet: Sand j] -Silt[],. Clay []' Peat Sandy.loam Clay Loam ❑ <br /> fHardpan ❑ AdobeA`Fill Material ............ If yes,type r - _ <br /> (Plot plan, showing size of lot, iocatiori of. system in relation-to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic PcP <br /> tank or see ge it permitted if public sewer is available within 204 feet,) <br /> p ;� ? <br /> - . Liquid Depth ....... .................. <br /> PACKAGE TREATMENT ] SEPTIC TANK j ' Size.............. ............................ . q P . <br /> Capacity ................ Type ..:3.., ............ Material.._. No. Compartments <br /> Distance to nearest: Well .':..............................Foundation ....................... Prop. Line ..._-- <br /> LEACHING LINE [ j No. of Lines ........:...... ......... Length of each line..----...........---- ---... Total Length N <br /> 'D' Box ............ :Type filter Material ....................Depth Filter Material .......:.........:.......................... <br /> Property Line <br /> Distance to nearest: Well ........................ Foundation .....--•--.............. p rty <br /> . r <br /> SEEPAGE PIT [ j Depth Di6rrieter ...............=-Numberled....... Rock it Yes .f <br /> F' - . <br /> Water Table Depth .....Rock Size .......i <br /> i _ Line _- <br /> Distance to nearest: Weil ...................................... Foundation .................. . Pro p. <br /> REPAIR/ADDITI0lV(Prev. Sanitation Permit# --------------------- .................... Date ............. 7................ <br /> Septic Tank (Specify Requireme+ts) ................................... --................_.._.. ------ ....--.-.---- ---------------------- <br /> _ :.........._..............:.- <br /> Disposal Field (Specify Requirements) ....._../ G�--•-- ' + �l•-../Sf 1..5��.�------�.................. ... <br /> i <br /> .. <br /> _............. <br /> ............ ..---- .. <br /> . (Draw existi.ng and required addition on reverse side) _ . <br /> k I hereby certify that 1 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: arson in such manner <br /> "1 certify that in the performance of the work for which this permit is issued, I shall not employ any p <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ................................. ........ ............ <br /> Owner <br /> 8y it a .. <br /> (If other than owner) <br /> ' FOR DEPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY .....r ri.t.._ .. -----------------------------.--•------ DATE ... . .- . `J ..._...._...__. <br /> r BUILDING PERMIT ISSUED ................ .............'-� ---_..::...................-:....:......_..DATE .:....:..:: .............. <br /> ADDITIONAL COMMENTS ..........-'.............................•--• --••---------•-----•-- .......................... <br /> ....... <br /> ...................... <br /> .7..............-.------....._.. :....._..... ... <br /> ;.� ..................... ._..--•--...... <br /> .................... <br /> ... <br /> E ............ . ........._..........._.... .. -... 9•_--e.---:-------............:_:....._........... - :.: - ........... <br /> :. .... .. <br /> ..................... 1. �.. . <br /> Final Inspection by: .... ... Date . ~-.._..fir........ . ........... <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> 114 24, •moo o.-.. x►s <br />