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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. . <br /> ......................................................... <br /> iCamplets in Tripllcottel <br /> /-1 h' <br /> Date Issued .................... <br /> This Permit Expires ] Year Prom.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 Incompliance with County Ordinance No. 549 and existing Rules and Regulations4 <br /> JOB ADDRESS/LOCATION ....... <br /> I 4...... 42Y CENSUS TRACT .............:............ <br /> Owner's Name � �CJI.._•.... :.....................Phone ......................_.. ......... <br /> } <br /> = - <br /> Address .... �.. Q.. . .-•-.1 ...... City ......................... <br /> .............•...... <br /> ..... <br /> Contractor's Name -- rp`' &nt <br /> -- <br /> --•---------.----------•_._License # _7/S`3_%.... Phone _�l�v�. _." .�I��- I <br /> Installation will serve: Residence House❑ Commercial❑T.raller Court 0 <br /> Motel ❑Other ------------------- ---------•-- -------- t <br /> Number of living units:.... Number of be m arbage Grinder —^--_ Lot Size _._- .- [L,S"�-•------••-•••••• <br /> I t 1�t ,�, ---...Private <br /> •- r <br /> Water Supply: Public System and name: f_..... d � - to ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Slit❑ Clay Peat❑ Sandy Loam ❑ . Clay Loam <br /> Hardpan 0 Adobe ill Material ............ if yes,type ............... ............ <br /> (plot plan, showing size of lot, location of system i n relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic stank or seepage Iii!permitted if public sewer is available within 200 feet,) ! <br /> t <br /> PACKAGE TREATMENT [ I SEPTIC T NK,t] Siae ..___..._-•_........-•-----.•---•_--_.___Liquid.Depth -------------- <br /> 11 <br /> CaCapacity Material_-------•-.--- ---- No. Compartments .....................� <br /> P �+ -Y....__�..----._.. Type �--•-----------�`- ---- <br /> Distance t�o nearest: Well . -==:Foundation ---------------------- Prop. Line ...................... <br /> ,r.d=.•,*ate.,„==--•---... <br /> ' ---- Total Length ---•--- -........._. <br /> LEACHING LINE [ ] No. of Lines 3-------------- � Len th of each line........................ -• - , <br /> - -- = •-_ 1 <br /> D' Box - Type Filter Material.. ... .' ".De th llter-,'Materlal . <br /> Distance t�earest: Well -•- -•-- Foundation �roperty Line ......................{. <br /> l . f r <br /> SEEPAGE PIT { J Depth <br /> :--... ..._... Diameter ----••---------• Number _.__.. ock Filled Yes ❑ No <br /> WaterTable Depth ...-•...........................••-••--••- •----Rock Size --------- -------- ----•-•----- <br /> Distance toned Well ----------------- ----.Foundation ----••------.-- Proo.LiLin�e ->._..--- •-�..._... <br /> t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----•••--- -----_ •-----•"-----• <br /> -------------------------------------------- Date, ) <br /> I : t <br /> Septic Tank (Specify Requirements) - ......./._...... ... <br /> � <br /> -/01 <br /> Disposal field (Specify Requirements) -••---•-•-1: „_._ ....._.. . ..... - • - }� <br /> -----------•-- -------•-----------------•-------••,-------------- ----------- .................... <br /> -------------------- <br /> (Dexisting and kequired addition ort rbverse side}l <br /> I hereby certify that I have prepe�red Phis applicatlon and that the work swill be dons in accordance with Son Joaquin <br /> County Ordinances, State Laws. ane# Rules and Regulations of the San Joaquin Local Health District. Hoene owner or liven- <br /> sed agents signature certifies the following: # <br /> "I certify that in the performance oaf tht work for which this permit is Issued, I shall no0employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." 't , <br /> lSigned -.-- ._!.......L..................••---------•---�,�•-- )_,Owner(...�"�/ <br /> B ....... ..._ ....... .......... <br /> 7.- <br /> Yl9'ri ...-----•-•-•--------------••-•----_-�_ Title _.. � . � <br /> other than owner) "6 <br /> j FOR DEPARTMENT USE ONLY ' <br /> F --- ---------------------- ------� DATE ./ .7..—.. ---------------- <br /> APPLICATION ACCEPTED BY ----- _. <br /> BUILDING PERMIT ISSUED --- ------ t--..-.l;------ -----_ ----------------------------- ..-----•----- ..DATE .............-----------------.-...-....... <br /> 7 <br /> ..............................ADDITIONAL COMMENTS _:.._ . ------- <br /> ' ... <br /> ----------------------------- ....._....... ............ ....... <br /> Final Inspection b <br /> .........................Date . ..-. .;- ;-7 - ........... <br /> p y: ..... <br /> EH 13 2L 1-613 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT :8/7h 3M <br /> � i <br />