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FOR OFFICE USE: <br /> �i APPLICATION FOR SANITATION PERMIT <br /> .................-----•---. ---•--- <br /> Permit No. __ ..... .. <br /> ;i (Complete in Triplicate) "' <br /> ......................... a <br /> .. <br /> This Permit Expires 1 Year From pate Issued. ©ate Issued . 7 <br /> Application is hereby mode:to the San Joaquin Local Health District' far a permit to construct and Install the work herein I <br /> described. This application'is made in compliance with'County Ordinance No. 549 a existing Rules and"gegulations:i <br /> JOS ADDRESS/LOCATION'.;...... _ .7. .._...�.�..lc%. .L�� .�„�.�.....- -. ENSUS TRACT <br /> Owner's Name _.. rri.P3"z !f °�' / .....................:............. ................Phone ..........,_....... <br /> ,........... .... <br /> Address �. 4� �!-t�aLs¢ r City�l <br /> ,.fes <br /> Contractor's Name '% - ...License # ........................... Phone <br /> Installation will serve: Residence r❑pc_rt�m t Housfl•Commezcial{]Trailer Court <br /> Motel ❑Other .................. .....---••-. ---- i <br /> : i <br /> Number of livingunits:_._- .�.._.. Number of bedrooms..._;.....Garbage Grinder ............ Lot Size ...................::....---- <br /> �, <br /> Water Supply: Public System iand name .:..............---..._...... . ----- ....Pr <br /> private ❑ <br /> Character of soil too depth of 3 feet: Sand 0 Silt❑ Clay ❑j. Peat❑ Sandy Loam ❑ Clay loam <br /> �Nardpan❑ Adobe o..,FIII Material ------_.----if yes,type............... ............ � <br /> (Plot pian, showing size of lot, location of system In gelation.to wells, buildings, etc.: must be placed on reverse. side.) <br /> NEW INSTALLATION: {No'�septic tank or seepagepitpermitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT ] I SEPTIC TANK I Size................................................... Liq ... --- _ <br /> • Liquid .Depth <br /> Capacity -------------- ..... Type'.,.................. Material__.:....._:........._.! No: Compartments .................. .. Zy <br /> Distance. to nearest: Well ............a..........................Foundation ................. Prop: Line ................... .. <br /> : <br /> LEACHING LINE ] Nolof Lines ........ ---------- - Length of each line_. ... ............ Total Length ....................... _-• Vl <br /> 'D' Box .... Type Filter Material .. ------ .Depth;-Filter Material ....... . . _. <br /> Distance to nearest: Well :, .. ' <br /> '•--- Foundation .............;--- - Property Llne .. <br /> -i <br /> SEEPAGE PIT [ l' Depth ------------------- <br /> :Diameter L._' : _ Number ... ................ Rack FilledYet 0 No ,(3 <br /> er Table Depth ..- _..-:.:--�". --•I ==---.:..F ze '' ..__s..:.:�--:_:-=�-- .::._.: <br /> • P p• <br /> a __ <br /> ock Si Pro Line ...................... <br /> Distance to-nearest We11 ounda#lon <br /> REPAIR ADDITION{Prev- . Sanitation:tation:Permit _ _:_._'.__ --..._:..---.- <br /> • ...... . ' ] <br /> _.;..........._:Date ... ......... <br /> Septic Tank(Specify'Re uirements] --- �• <br /> Disposal Field {Specify Requirements} -;.i:__,P��`�-�w� ;� �`-�!�•_f c�� ,��,� _'c�..���� �- � <br /> x <br /> t ; <br /> a <br /> I _ • _•.... <br /> _......_� <br /> ..........-------. _ .................................'.............:..___._....................__. <br /> = (Draw existing and required add!Non:; <br /> ,on reverse side) . <br /> 1 hereby certify that i have prepared this application,and `th at.the.work.*ill_be.done.-ln:acterdance,.wlth.Seip J6arlultt <br /> g local Health,,District. Hants owner ar Ilten- <br /> County Ordinances, State Laws and Rules and Regulations!of the Son Joaquin <br /> sed agents signatare certifies the following: <br /> "I certify that in the performance of the work for which:this permit.is issued, i shall.:not.employ any. porion.in svch.mantie► <br /> a3 to become ( to orhmon•s pensation.laws'of California." <br /> e <br /> S'gned i <br /> -- ------------ -•---- - -- <br /> B . Title ,. . <br /> BY <br /> ---------------- <br /> -------------- <br /> � <br /> (If other than owner] z . .-. <br /> I, <br /> FOR DEPARTMENT, USE ONLY . - i <br /> APPLICATION ACCEPTED BY .-L-... DATE_ 1l.n.�,�' ? 5 : <br /> BUILDING'PERKAIT„ISSUED'-.'W---7------� � �. :�» ... .. ..............DATE -:. -•--•- ..----._.. ........ <br /> ADDfTIONAL COMMENTS ...11-------------- -_.. <br /> ----------------------------------.-.!!1M--....-------------•---••------------------•-- ............ ••------••--•----- ------ ... -------_------------------.........------------ <br /> ------------------•-- •----------------� ---------------••----------------------------- -------- ----._-----------------------------------------• ...----.---..... ....................... <br /> EH <br /> ----•------------------------- ................�....__.. •--- -• -- ,�.�.._... <br /> Final inspection by. ... �` `��. •-----•. . ...._ .... ©ate ....j/..-/tl.- <br /> 13 1-6 SAN JOAQLiIN LOCAL HEALTH DISTRfCT B/7h 3M <br /> .i <br /> I` � <br />