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FOR OFFICE USE: r <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No_ ______________ <br /> _ <br /> (Complete in Triplicate) ....... i <br /> .... ............. This Pe It Expires I Year From Date Issued 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 /> JOB ADDRESS/LOCA-TION ......._f� _.__. ._. CJt?7�h-/��9?t/ ........................ <br /> .........CENSUS Tits a <br /> Owner's Name ..V.�-W.._. a <br /> .. ._.... hone <br /> Address 7U. 4 IJT?./�1d..¢'T✓.d._..... Citye71�! i�. !1............. <br /> _.......... ,..., .............. <br /> Contractor's Name ' <br /> -------------------••--•---.........-----•... License # --...................... Phone ............. <br /> Installation will serve: Residence®Apartment House❑ Commercial❑Trailer Court <br /> a <br /> 11 Motel ❑Other ------------------------------••............ <br /> Number of Living units:..._/_------ Number of bedrooms ....rf------Garbage Grinder ....._ ..... Lot Size ..~�. �'�� <br /> ......................... <br /> Supply: <br /> Water Su I Public System and name <br /> ..........................................Private ❑ <br /> Character of soil to a depth of 3 feet; Sand❑ Silt❑ Clay ❑ Peat❑ Sandy loam 0 Clay Loam ❑ I <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 ori reverse side.} <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ ] SEPTIC TANNIC{ ) Sixe................. <br /> ---• ------.-- . Liquid Depth <br /> a i <br /> Capacity ----'-- ------ Type -----------•-•------ aterial----- --------------- No. Compartments <br /> Distance. to i nearest: Well .......... ....... .......,-•--••-__F undation ----------........... Prop. line ...................... <br /> LEACHING LINE [ j No. of Lines <br /> tt ........................ Length f.each lin . ...... Total Length ;i <br /> 'D' Box ._-.'.�..---. Type Filter Materf .............. . ...Depth .Filter Material <br /> Distance to nearest; Well _._-------- -.-._-_-.- Fou dation ---------------------•-. Property Line ----- . <br /> SEEPAGE PET [ 1 Depth ------ - ----------- Diameter <br /> mbar _._____.•................... Rock Filled Yes ❑ No ❑h I <br /> Water Table Depth .. ....... . ......•--- --- -- Rock Size ............................ <br /> ::.pDistance to dearest: Well .. .._ --------Foundation -------------------- Pro Line ................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...... ..........:....•---- --.._...___-_... Date __---_...-.•-------•- _--- <br /> ..M� } . <br /> t <br /> Septic Tank (Specify Requirements) __--_------ - _..___.___. <br /> --------------------- _.... <br /> Disposal Field (Specify Requireriients) -----------___________________ <br /> I <br /> ------------ •--------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have-prepared this application and that the work will be done In accordance with San •loaquln <br /> County Ordinances, State Laws, andlRules and Regulations of the San Jo' aquin Local HealI&Dlstrict. Home owner or licen- <br /> sed agents signature certifies the following: f <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 bec me suubcj)eccta W rkman's Pompensation laws of California." <br /> Signed . `_ /Z --- _ r <br /> Owner <br /> BY --- . ------ I......... title <br /> ------ --------------- - •-•------- <br /> (If a#her than owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY —� <br /> --J------•--••--•----__-_..._.. ,.._..--- •-- . ,._..._ DAT( �a.- <br /> BUILDING PERMIT° ISSUED -- ------ �`�-•-- ------------------ ........................................DATE ................. <br /> -------...-•------ <br /> ADDITIONAL COMMENTS ----------- <br /> ----•--i-------------.---------------------------------.....__....__....-.-........._._.....__....._. <br /> •---...----- •-------- i--------------------------------------------------------------------- <br /> -----------------•- ............•............. <br /> Final Inspection by <br /> ---- -------------••----------•---------- ------------------------- <br /> -----... f -----•-••-----------• --------------------- ------------------------Date .....2..... '7_....._...--- <br /> 2 1-� 14-,v. [ SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />