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FOR OFFICE USE: g 1001k <br /> - 7 /� <br /> APPLICATION FOR SANITATION PERMIT �(/� 7 <br /> ................. ----•---•------- ---- - Z <br /> jI Permit No. .-�.:�:-Sy__. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year from Dal*Issuod 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 /> r _ <br /> E . <br /> JOBADDRESS/LOCATION .. �... ...,�� _._.".� .: .. _.o- AWI .....f .CENSl1S TRACT 1....,5:.-............ <br /> i <br /> Owner's Name .................... .� U _ rD �..... ---------------------- .........................................Phone ...... <br /> Address ...................Q�.I....... .- _........................................ City ��!�i•��1-... <br /> Contractor's Name <br /> ..........�_.�j...150!1�`s_.-..r? _.�17. . .. nse # ........................ Phone ..`137_ 03` <br /> O <br /> i CIO <br /> Installation will serve: Residence[&.Apartment House[] Commercial❑Trailer Court 0 <br /> € Motel ❑Other Gt <br /> [�a �6 — <br /> Number of living uni#s -- <br /> : .:-.__•/_ Number of bedrooms ...... ...__Garbage Grinder ............ Lot Size ...o�.................s�.........-.......:.<� <br /> Water Supply: Public System and name -..:......................_---••---.._-.................. .....................Private Qrr. <br /> t <br /> Character of.soil to a depth of 3 feet: Sand j] Silt❑ Clay ❑ Peat Q Sandy Loam 0 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 sld .) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted If public sewer is available within 200 feet,j <br /> ' PACKAGE TREATMENT SEPTIC TANK . Liquid Depth <br /> l � ��'" Size........ .............................•- ......9. <br /> Capacity --19 _ _.. 3-------- Material f� No. Compartments <br /> .Ei L� ..__ Type . �� - �------ -...2�;........,�.. <br /> EI Distance to nearest: Well ------� 0___ Foundation .._.._IC.. <br /> --•---•---. ._.._. ....... Prop. Line ... <br /> ................. <br /> LEACHING LINE No. of Lines g ^o.... ...... Total Length ___-1 ?._.. <br /> I ---....-�-.. --- Length of each line..__.._.r5_: .. � <br /> u 'D' Box .._:`:------ Type Filter Material O$V_11- ___..Depth .Filter Material .........(2 <br /> ................... <br /> -----.... _.. <br /> i� Qistance to nearest: Weft __ .......... Foundation .... Property Line ....��.__._...� <br /> SEEPAGE PIT Depth ----S-5__ ._... 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 /> I�Septic Tank {Specify Requirements) ......................... -------••------------------------ ------ ----••---• ............ ...............•........... <br /> :.Disposal Field {Specify Requirements) _____________ <br /> -- <br /> --------------------------------------------I-----•- •----•------------------------------- - <br /> ..................................................... <br /> ------------­---- •----------------------------------•--------------=--------- <br /> --------------------------------------------------------------------------------------- <br /> ..-------- ..._.....---........_.. <br /> y <br /> {Draw existing and.required addition on reverse side} <br /> I hereby certify that 1 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. Hance owner or licen- <br /> sell agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I sholl not employ any person In such manner <br /> ft <br /> as'to become subject�to Workman's Compensation laws of California." <br /> Signed -------------- Owner <br /> Owner <br /> By.. ------------ --••--------------- - ---------------------------------------------'Title ........ .............. <br /> !� <br /> (if other than owner) <br /> FOR DEPART ENT USE Of4ky <br /> APPLICATION ACCEPTED BY - --- ---- __. DATE .- 5 <br /> BUILDING PERMIT ISSUED----------------------- -._ . _ <br /> { -- --...----- DATE • --•-•---- ------------------------ <br /> , <br /> ADDITIONAL COMMENTS -_-------•............... ... <br /> •--------_--- ---•- ------- <br /> ----------------------------------- f� <br /> ' <br /> Final inspection by: ---.-..-- --- - -- --•--.. . --- -- - •- ----------------....-----------�................---------._._Date <br /> Eti` 13 24 —b$ Rev. 5MSAN JOAQUIN LOCAL HEALTH DISTRICT 8/7$ 3M <br /> R <br /> s' <br /> L <br />