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FOR41L OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> r:..:.............................• -•-------•----._ Permit No. ................ <br />' Komplete'ih Triplicate) <br /> ...:............................ -------- _ <br /> r` ................... . <br /> . � ..Delo Issued`.-2'� 7 <br /> ------------------- This;PerMlt Expires t 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 /> a <br /> I <br /> JOB ADDRESS/LOCATION -.-.�ff2.�-:..-.5�... Y�f f' f.• d ............. <br /> Owner's Name ........................................................ .'.......... ....Phone .........................,.......... <br /> Address .._.. .!? :.................................. - t . . ./7............ ...... <br /> Contractor's Name _. - � __...License 91Ecr l.'��.s �1. -? � ... <br /> --r._ . .I�Q �.�........................•---•- `� -.- Phone <br /> l Installation will serve: Residence%Apartment House Commercial OTroller Court 0 <br /> Motel [I Other ................................----. ..:.. �. <br /> r� �. <br /> Number of living units:___.__ Number of bedrooms ...__Garbage Grinder . .. Lot Size lr��.•,�C-: _4?...••.......• <br /> M Water Supply: Public System and iname _e. .... .._.f '..:sv?rd 'CfI! .Z.................. <br /> ................Private L] <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay ]] Peat 0 Sandy Loam Q Clay Loam ❑ <br /> } .Hardpan 0 Adobe f9 FII M6terial ......... If yes,type............... ... ....... <br /> { (Plot plan, showing size of lot, location of system in relation`rto 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 204 feet,] <br /> PACKAGE TREATMENT SEPTIC TANK r Siie................. ........:. Liquid`Depth .__ -__ , ..... ..� <br /> `"Copacity = Type "3~ _ Material....------...... " No:- Compartments ................... <br /> ' Distance�.to nearest: Well ..._:S __. .._......_......____Foundation ...-....._•-__.---- - Prop. Line .................... <br /> 1 LEACHING LINE i ] No. of Lines -----------------------f length of each line.........................I... Total Length ,__......__..:.............. <br /> 'D' Box . ....... Type Filter Material __...••.............Depth Filter Material ..:.-__•............................I........ <br /> Distance to nearest: Well ............................ Foundation Property Line <br /> SEEPAGE PIT [ ] Depth ...:................ Diameter _.. .......... Number -___-...._ ........ Rock Filled Yes ❑; No C <br /> Woter Table Depth <br /> ...........................Rock Size <br /> ' Distance to nearest- Well _-___. _Foundation Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation-Permit.#:............. ........... . .. Date.... ••) <br /> i <br /> Septic Tank (Specify Requirements). --------------•-..-. ,r> .................... <br /> } Disposal Field (Specify Requirements) --• Zvi....... <br /> t <br /> ilk.--•..........:... ............. <br /> 1 __..._... �_______-- <br /> ---------------------------------------.--.�.____ .........................--------------..........................................................:._..__:.....___.__._.._............_..__. <br /> P (Draw existing and required addition on reverse side] <br /> I hereby certify that I have prepared.this.application-and.th otTthe..work_wlll be done In. accordance with Saes Joaquin <br /> County Ordinances, State Laws, and Rules and 'Regulations of the San Joaquin Local IHealth'Dishict. Hance 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 /> Signed -------------------Per <br /> ..... ------- Owner <br /> Y ! <br /> � B -•--- -------------------- _�,.--------..........:... Title _.. •- -- --��..._.-_..:..--_...___._.....(If han owner) <br /> FORfDE T S NLY ' <br /> APPLICATION ACCEPTED BY ----- •-•-----------• --- --------- DATE _-...�'.. '��..-.-_...... <br /> BUILDING PERMIT ISSUED ------ - _......... :'_DATE''._ .............................. <br /> ADDITIONALCOMMENTS _.------ '------- -- ----------- .........................................................................................---••--- ••-..........- ,..._ <br /> ----------- ------------------------------------------------------------ -.....%........_. ......................... ............ . .........................- -.....--- ---•• -- <br /> ................ ------••---•---•-------.. _------ - <br /> -------------- --------•-----------_________----------' ......... . ...... �`` +� <br /> Final Inspection by-- -•-------------------!....- - - _ ......Date _[x'o�.:�� ............... ......... <br /> EH 13 2L - 1-6.6 k Rev. 5M SAM JOA IN CAL HI: RICT 8/7]! 3M <br />