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FOR OFFICE USE: « ' <br /> APPLICATION FOR SANITATION PERMIT <br /> .............. ...........h......_.................... >s <br /> .. .................. <br /> (Complete In Triplicate) Permit No. .._.... .- <br /> ..... This Permit Expires 1 Year From Date Issued Dote 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 Regulationsc <br /> JOB ADDRESS/LOCATI/ N+'./ ... Jl_„_. .l /11.1 .--_ . ....................CENSUS TRACT _.........-..`-.... r...... <br /> Owners Nome .. �h�. =C-G ' - � �!�1 .........r.....................................Phone . _&2. 6- &79 <br /> . <br /> Address .............� Q -. .. ' ..amu`-/. E - - •--•-- ---91...... city ...--..- <br /> .................. <br /> Contractor's Name / license <br /> # _1g .�/-- Phone <br /> Installation will serve: Residence 0 Apartment House]] Commercial['Trailer Court 0 <br /> Motel ❑Other --- ----------•-•--•------------------------ <br /> Number of living units_____________ Number of bedrooms ............Garbage Grinder ------------ Lot Size ___ _ '--'. ................ <br /> Water Supply: Public System and name ............................ ........•--••---•--------.....---•--......--•------.............----•----.......Private fits <br /> Character of soil to a depth of 3 feet: Sand 12ilt❑ Clay ❑ Peat❑ Sandy Loom 0 Clay Loom 0 <br /> Hardpan ❑ Adobe 0 Fill Material ............ if yes,type ............... ............ <br /> (Plot pian, 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size._ 411.._9................ liquid Depth _15_0 <br /> Capacity /4-049----- Type _ ci? Material No. Compartments ---�...........p <br /> Distance to nearest: Well -..81 . -A....................Foundation ..... Prop. Line _s� <br /> sN <br /> LEACHING LINE [ ] No. of Lines -------3------------ Length of each line.... .h . Total Length ......... <br /> 'D' Box ...j...... Type Filter Material __- � fepth Filter Material ............... ...........I.....__.%A <br /> Distance to nearest: Well .Ac:-.O.......... Foundation ---- -..-.---... Property Lina .... ....... <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(Prey. Sanitation Permit# Date ) ` <br /> SepticTank (Specify Requirements) ....... ..............................................................................................................._.................. <br /> Disposal Field (Specify Requirements) ----------_-_-- • ------•-------•---- -------•-•....----_- --------------------------- <br /> ------------------------------­......­­­------I----------- ---•------------------------------------------------- ................-....-...............•........ ............I...........----------- <br /> JDraw existing and required addition on reverse side) <br /> 1 hereby certify that I have.prepared this application and that the work will be done inaccordancewith 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,,) shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed . • ----.._ .. .. — ..-- --•--•- -•----- --------------------------- -- Owner <br /> By .� ............... Title _;0111 --1 - <br /> lif other than nerl <br /> OR DEPARTAAENT USts ONLY <br /> APPLICATION ACCEPTED BY - -----. . _J. -- . DATE .. . .r.7.G__ <br /> BUILDING PERMIT ISSUED ., -_-.-.__DATE -------------- <br /> ADDITIONAL COMMENTS ....-_---------------------------- -.-_------- ---------------•---•-•----- <br /> -----------------•-----..------ - ---- ---- -- --•-------------------------------------...------------------..----------- .... <br /> ................-..... <br /> _..-- ---....-- •-••----•-• •- •-•----..-.--.. <br /> ------------------------••-.... .-. . --. ------ . ---q- --- •w--^� <br /> finalInspection by; -------- ... ---...--•----••----------------------•-------...-..._ ....--..----------•-•--..----.Date ---- --�°1----.!-- ------..-.--------- <br /> EH 13 2b 1-613 v 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />