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OFFICE v`sE <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. .. <br />...................................................._.... (Complete in Triplicate) <br /> p Date lssued /0-/ � <br /> This Permit Expires 8 Year From Date <br /> Issued <br /> ............................................ �3 � �Q3 <br /> Application is hereby.made to-the San Joaquin local Health District for a permit, to Can and Install the work herein <br /> described. This application.ls made In compliance with C unty Ordinance IN, -Si19 and existing les and Reg <br /> ulatlons� <br /> r cJ p0 t�Mrtr�✓�• 3 Cy D r r <br /> ,2l ' CENSUS TRACT <br /> .: -•---...--•--•-•................ ... ............ . <br /> .lC+B ADDRI:55/k I N � ..._ .ti.... ---- • ----•-•----• F .. .......................... - <br /> Owner's Name • -- ................................... .......:... I .. ...... hone <br /> .. _r�. ....: ......... :q. ....... .. . `...r.._........._ .... <br /> Address, .... c �.- `�.1... Phone rKi•` �"� . <br /> .. F .- <br /> Contractor's ame _ . ............................ <br /> License# <br /> installation will serve: • Residence[Zj'Apa mens House-Q.Commercial(]Traiter Covet 0- <br /> motel ❑Othe►�..............--....-----------------�. r - <br /> Number of living units:. .--- Number of bedrooms - --.:Garbage-Grinder-!:- 't_..-Lot Size ....... <br /> Water Supply: <br /> Public System and name -------------------.................................. ..•--•---........Prlvaro <br /> Character of soil to a depth of 3 feet: Sand Silt❑ " Clay []. Peat❑ -Sandy Loam ❑ ' Clay loam D <br /> Hardpan ❑ ­�_Adobe❑ fill Material ............if yes,type............... .... <br /> !Plot plan, showing size of lot, locatloW of system In relation to wells, buildings, etc. must be placed an reveres side.? <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted Ifyublic sewer is ovaHable within 200 feet,) <br /> e. <br /> y . Liquid Depth .....vim_ .�................ . <br /> PACKAGE TREATMENT [ , SEPTIC TANK f&Y Iz -• , • --d ............. <br /> Capacity &.0,0-----•- TYPS `_Moterlal.Le.-fit....... No. rCompartments ...� .• ............. <br /> r Prop. Line ... ..., ? <br /> • Distance to nearest: Well .. .........................Foundation .3..!52Z <br /> len th of ea )Ins .�. �t�- ......... Total Length 1 l Q.,. . .. . .... <br /> ;.i=ACHING LINE [L}- No. of lines - -'-••• - g • <br /> 'D' Box . � Type Filter Material ,Sj.. . Ct4epth Filter Material ........................ .i <br /> Distance to nearest Well <br /> ..la,C _. .. Foundation 4 .....•••••••• Property kine �.+".•- <br /> r Diameter Number V Rock Filled Yes ❑ No ❑ <br /> SEEPAGE PIT� [ �. .Depth .---=.......�..._... ................ �.._..........................._._.....---• - <br /> Rock Size <br /> Water Table-Depth........:....................................... G <br /> .� rest: Well .......................... .............Foundation ...... .......... Prop. Line ...............••... <br /> Distance to nee ','' {. <br /> REPAIR/ADDITION(Prev. Sanitation Permit#............................................. Date ......................:...........j I, <br /> Septic Tank (Specify Requirements) ......................................... . ..................................... ..................-............._.............. <br /> ............ <br /> 4}isoosal Field (Specify Requirements) ................... ............................................................-•---........._..............••••---•-- <br /> --------•-•••-----------••....................................................................---•--••--- ......................I.............. <br /> ••------ ----- <br /> ....... ...._........................................................................................... <br /> -- ---- - ---• ---- . <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this application and that the work will be done In accordance with Sato doagui � <br /> I County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heo!!h District. Home owner or iicen-` <br /> sed agents signature certifies the following: <br /> '°i certify that In the performance of the work for which this permit is issued, I shall not employ any person In such manner <br /> as to betas bje t to W an' ensation laws of California. <br /> ............... Owner ` <br /> _-,�gned 7 .......... ..... ..... <br /> .- <br /> By ......................... . ... ! .. ..-- . �it1e -.....-.-.. <br /> (If other than owner) ` <br /> FOR DEPARTME Y <br /> APPLICATION ACCEPTED BY _.-. ........ DATE' <br /> 1�..f :7i ...":::. ........ <br /> BUILDING PERMIT ISSUED .......,.-_. DATE-;- ........... . <br /> ........................ <br /> ADDITIONAL COMMENTS <br /> . ------ -----------•.------.. -.--------*....... _- ............ <br /> ' .... -............................. ... ....•.�...... ...... <br /> L - - Date <br /> .......... <br /> Final Inspection by: ..------------�---- . ... .SAN JOAQUIN LOCAL HEALTH ...... <br /> - .•-.••.-.- <br /> EH 13 21t 1-66 Rev, H ICT 8/7a 3M <br />