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OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> _...... ----•-- <br /> �7 <br /> (Complete In Triplicate) <br /> Date issued .. <br /> ' This Permit Expires 1 Year from Date Issued <br /> Application is hereby made to the San loaquin 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 /> .. ..... .. <br /> JOB ADDRESS/LOCATION .�.Q. .,.G. .. <br /> ....-..CENSUS TRACT .. .�-•. •••• -•y�• <br /> P <br /> Owner's Name ... _ .....�.,rrt.t��... ...�: ..........:.................................... hone <br /> } ...• ............. ...................... <br /> M Address g.G'�Yi ......... ,...... C .... ,�...... Phone Q 7 <br /> .._. city <br /> Contractor's Name E�/ ...............L nse Q. -�. .. ....... <br /> Q'�' .. . .... <br /> i • 1... <br /> Installation will serve: Residence Apartment HouseO Commercial ❑Trailer Court 0 <br /> Motel ❑Other .._------- ................................ <br /> Number of livin units .-- Number of bedrooms Garbage Grinder Lot Size .. •.••••- •• •- •--••- •................. <br /> 9 <br /> Water Supply: Public System and name ..... Private, <br /> Character of soil to a depth of 3 feet: Sand b Silt❑ . Clay ❑ Peat❑ Sandy Loam-4', Clay Loam ❑ <br /> Hardpan ❑ Adobe'❑ Fill Material If yes,type ............... ............ <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,) s `� <br /> I <br /> PACKAGE TREATMENT SEPTIC TANK�•j Size... /gy p..................... Liquid. Depth .................0 <br /> [ ] � . <br /> TYpe .--...... <br /> Capacity " Materi �e."_.....-..... No. Compartments <br /> 'al <br /> y ,I- o <br /> -. Distance��to nearest: Well .............................. oundation J-0.............. Prop. Line .. ....... Q <br /> No. ofd Lines :•--------• Length,of each line..-.-_��. -........• Total Length,`( .....•.••-••••- <br /> LEACHING LIN [ ] {� <br /> . ....•••............................�. <br /> Depth Filter Material . • <br /> ©' Boxi...�-.---- Type Filter Material ....._fit. <br /> p0 .... No Property Lina •----....... <br /> Distance,to nearest: Welt _. Foundation ....-.-•- p tY <br /> Depth )(./.�`�./�'�A. Diometer ••....... Number ........I--_•.---........ Rock Filled YesA No <br /> I r: Water Toble Depth .. ---• ..........................Rock Size ......... � s <br /> Distonce,to nearest: Well -.---------.•---•-------------.........Foundation .................... Prop. Line ..................... <br /> s <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ......•__---------------------------------- Date ..-•......:.........••••........ S <br /> Septic Tank (Specify Requirements) --------------------------------- ----.....................:: .................... - <br /> Disposal Field (Specify Requirements) -_:n <br /> - ...............•.----.._....I........... <br /> ,' <br /> - - <br /> ------------------------------------------------------------------------------- <br /> } _ --- .....__ ----- -- ------------------ ------•----•-------------------.-------•-• •------•---••----- -- .................._..... <br /> --- ------------- •------------ a <br /> �{ �j !Draw existing and required addition on reverse side) <br /> 1 hereby certify that ! have prepared this application and that the work will be done In accordance with San Joaquin <br /> G County Ordinances, State Laws; and Rules and Regulations of the San Joaquin Local Health:Districf:Hams owner or )leen• <br /> sed agents signature certifies the following: <br /> t <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 /> Signe_d - -- - ---------- -------------- Owner <br /> Title - .- --------------•-- <br /> BY -- •--- ---- --------- --- <br /> (If <br /> (If other than owner) <br /> i FOR DEPARTMENT USE ONLY <br /> ' <br /> ;.: DATE.. .. F <br /> J <br /> APPLICATION ACCEPTED BY .. - --- .:. .•DATE ------------ --------• <br /> ------ <br /> BUILDING PERMIT ISSUED <br /> i ADDITIONAL COMMENTS ......... ----------•- -,----- <br /> i ----• ..._..----- ------------- ---------- ........ <br /> 4 Final Inspection by: ... <br /> �......... _.._-- ------------ ----------- Date .....'�Q -� <br /> ' EH 13 21� 1-bi3 t v. <br /> SAN fOAQ7UlN tO AL ---HEALTH DlSTR#CT 8/7h 3M <br /> t <br />