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-�EOR.4IV10E USS: <br /> APPLICATION FOVSANITATION SANITATION PERMIT <br /> ---------- _ Permit No. <br /> (Complete in Triplicate) y <br /> ------------- ------------------ ------------------ p _ Q <br /> SExpires <br /> Date Issued --�---~�.-�/ <br /> -- ------ ---------- ------------------------------ This Permit Ex ires 1 Year From Date Issued 4 <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 _-�00 1E 4%T---1`�_/��------ f'.�------------------- ----- £NSUS TRACT -------.-----------•-•---- <br /> Owner's Name .__ 11� p = -------Phone ----------------------- <br /> Smrc <br /> Address -.----- 79 .- •.- I .Aq � --- 1 ;City <br /> Contractor's Name > --- --- t�Cr ---���`�"9/A6"" -----_-�� 1,--&- icense# ���'3_- Phone-.:____r_:_ ___ <br /> Installation will serve.. Residence Apartment House❑ Commercial :❑Trailer Court ',0 <br /> i <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'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ;❑ <br /> Hardpan ❑ Adobe 'D Fill Material ----- ------ If yes, type ____________________________ U . <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) V <br /> NEW INSTALLATION: (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 -------------------- Material------------- ------ No. Compartments -----:---------------• <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----------------­­_ <br /> LEACHING LINE { ] No. of Lines _____ __________________ Length of each line--------------------- _ ____ Total Length ----__._______--__-_______- <br /> 'D' Box ------------ Type .- <br /> Filter Material ____________________Depth Filter Material _________________.-. .--------------------- <br /> Distance to nearest: Well ---_-------_------------ Foundation ------------------------ Property Line _..__--_____._____-:---_ <br /> SEEPAGE PIT [ ] Depth ------_ ------------ Diameter ________________ Number --------------------------- Rock Filled Yes ❑ No �❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest. Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank {Specify Requirements) - --------- --- -------------------------------------------------------- -------- -------- <br /> -------- --- <br /> 1 /y !I v <br /> Disposal Field {Specify Requirements) - __._1r'�'�l�t�✓�-�-----� {-----=-�t�-------t----�-- --'��� <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 subject to Workman's Compensation laws of California." <br /> Sig&4-k, <br /> -, ------------- -------- <br /> ---- - Owner <br /> ,,y Title ---------------- -- -------- <br /> t i�i` i" -'Irt�A-- _illi,Q8'8l�.. QW- 'A�NtC <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED - ---------------------------- - -- -- ------------. DATE ( <br /> ------------ <br /> DATE ------------------------------------------- <br /> -L -- - rBUILDING PERMIT ISSUED � � <br /> , �ADDITIONAL COMMENTS <br /> -- ------- --- --------------------- ---- -------- ------------------------------------------------------------------------------------------------------------- - --- <br /> ---------------------------------- <br /> -- <br /> ____________________________ _ _______ f+ <br /> Final Inspection by. - Date ----t_5 7_ ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 r . 1 `8 Rev. 5M <br />