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FORS" FFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --- ------------=---------- ------------------- <br /> Permit No. �+�:__5�9 . <br /> (Complete in Triplicate) <br /> ------------------- <br /> � Date Issued <br /> ------------------------------------------------------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to-the San Joaquin Local Heajth District for a per 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 /> JOB ADDRESS/LOCATION .-- c 3 9 T/d------------------------------------------------------=----------CENSUS TRACT -------------- ----------- <br /> ------------------- <br /> ---------- <br /> TeH P'hone <br /> ----- ----------------------------Owner's Name ------------ <br /> -------------------------------------------- <br /> Owner's <br /> ------------------------------ <br /> ----•-Address ------------•------------ -------- . CitY <br /> Contractor's Name ---- .nl�---------------------------------- ------- ---------.License # -------­--------------- Phone --------------------------•--- 4 <br /> Installation will serve: ( Residence Ce/Apartmenij Ho se E] Commercial <br /> -]Trailer Court ❑ <br /> Motel ❑Other ----------�'-'-------------------------- <br /> Number of living units:----- ----- Number of bedrooms ­3-------Garba-ge Grinder ------------ Lot Size --------------- y <br /> Water Supply: Public System and name ----------C/9-/ 74e------------------ ---Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt o' Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam lC� <br /> • f <br /> Hardpan ❑ Adobe'[]Fill Material ----- ------ I#yes,type ---------------------------- <br /> (PI'ot 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,) <br /> PACKAGE TREATMENT { ] <br /> ."SEPTIC [ ] � - <br /> SEPTIC TANK ; Size =' Liquid Depth -------------------------- W <br /> dci Type --------L--!--------- Material-------- ---------- allo. Compartments ------. --------- . <br /> Cap tY ---- ------------ Yp <br /> Distance to nearest: Well -------`---=------------------------Foundation --f---------------- Prop. Line ---------------------- <br /> I <br /> LEACHING LINE [ I Nc. of Linos --------------------____ Lerigth of each line------_----------.--------- Total Length _________-.-______----.__-- <br /> 'D'j Box ----- ------ Type Filter Material ____________________Depth Filter Material -------------------------------------------- f <br /> ! _____ Foundation _________ ____________ Property Line __.__._-________ <br /> Distance to Well __________ ________ ------- <br /> SEEPAGE PIT [ ] Depth ------ ------------ Diameter _ ''t______-- Number -------------- ------------- Rock Filled Yes '❑ No i0 <br /> l 1�' <br /> Water-Table:Depth­-------------------==C;;_:----------------------Rock Size ------------------------------ <br /> Distance to Inearest: Well ------------- -------------------------Foundation ----------__ -.___- Prop. Line -----------------_-_-. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- '-- ------------------ Date ----------------------------------) <br /> I � <br /> Septic Tank (Specify Requirements) ---v�.�- <'� / nit --—ra ----------------•----------------------------- ---- -- ----- ---------- <br /> A <br /> Disposal Field pecify Requirements) --- 1`�- ' 7 fy� �-i-ec.� ----- --1�-(-�i-nles- <br /> 1 <br /> i'--------------------------------------I- --------- --- -- ---------------------- ------------------------------------------------------------- 1 <br /> ;(Draw existing and required addition on reverse side) <br /> -- --- --_ . . - - - <br /> I hereby certify that I have prepared this application and that the work will be done in -accordance with San Joaquin r <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health;District. Home owner or liven- <br /> sed agents signature certifies the following: l i <br /> "I certify that in the performance of the work for which this permit is issued, I sha11 not employ any person in such manner <br /> as to beco subject orkm n's Compensation laws of Californid."'� <br /> Signe f�-�---- t��''wt'�'t-,------- ---------------------------------------- Owner ' <br /> o , <br /> By ------------------ --- ------------------- ' -------------. Title -----------------------------------=--------------------------=--------- <br /> (If other than owner 3 <br /> V FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ----- ----- ----------------------- --------------------------------------- DATE -----4Y-�7 #---------------- i <br /> BUILDING PERMIT ISSUED Af III <br /> --_-- ----- ATE <br /> AD ZONAL COMMENTS - r_ �`' / If _f t� <br /> h---- -- <br /> -�ij=------ --- - - - <br /> --- - -- --- <br /> - - --- ------ --=�------- ���c�/ �'� _�'� -r ----------- <br /> 0 <br /> �-- - <br /> r4 <br /> Fi al nspec- b : ---- -- V -----•-------------------------------------- ate �" <br /> �f1 C/AL HE LTH DI <br /> !!!II`��' � �1 �V �� ♦ qty <br /> E. H. 9 1-'b8 Rev. 5M <br />