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_ L FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .�5 3 <br /> 4Permit No. --------- - •-- ---- <br /> - =--------- -- (Complete irZ Triplicate) <br />. --------- - --------------------------- --- <br /> ate Issued <br /> -------------- D <br /> This Permit Expire 1 Year From Date lssgpd, <br /> - <br /> , <br /> Application is hereby made to the San Joaquin Local Health District,•for6-permit to construct and install the work herein <br /> described. This application is made in compliance with Co unfiy`Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - ------lr_� ------ ---------------CENSUS TRACT -------- <br /> Owner's Name ------ �-�5.1 ---- <br /> ------- -I—---------- --------Phone-------- ----------- --------------- <br /> ----=- -�--------• cityGl�]_��.� ------ <br /> Address ------------ <br /> -------- �. -.. - --_ r� I <br /> Contractor's Name ------ --------- ----------- - ------------ 1 <br /> --------".✓Lic..e,nse #, <br /> ---------------- ------- Phone •------ <br /> Installation will serve: ResidenceXApartment House E] Commerc-ial:❑railer Court i❑ I <br /> - ' s <br /> Motel ❑Other ------------------------------� ;-`=- --- <br /> s 0.1 <br /> ---_ Number of bedrooms -3------Garbage Grinder Lot Size <br /> Number of living units:__-/--_ - r <br /> --Water Supply: Public System-and name ^"=` - I--- - `=---=- ----•----`mP ivate <br /> Character of soil to a depth of 3 feet: Sand'E] Silt I-]. Clay E] Peat❑ Sandy Loom ❑ Clay Loam <br /> l <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 side.) <br /> P seepage pit permitted�if..public sewer is available within 200 feet,) 001 <br /> f NEW INSTALLATION: {No septic tank or � `J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size- -X-�t�.._x--- ------------- Liquid Depth ---7-0-------------- 4 <br /> Capacity -!�©--------- Type - MaterialCR `10. Compartments <br /> ------------•-- <br /> �.�--{{�� neFour�dati Total <br /> ''Length Lin ------- <br /> Distance to nearest: Well ----so --------------------- � � <br /> LEACHING LINE No. of Lines ------,rte - Length of each'li <br /> 1.�- t <br /> D' 13ox ,ir '_ Type Filte�'Mate��al _ - -- ---Depth Filter rMaterial <br /> -_ <br /> j .fir. - <br /> ",- .� Property Line -- <br /> Distance to nearesr: -WeII --- ----___�_-)_- Fqundation , <br /> �l �'�' L�__ Number - -_.-- �---- Rock Fill d' Yes No .i0. <br /> t SEEPAGE PIT Depth f2 `:.--- ------- <br /> el <br /> Diameter + r� tr <br /> �— Wcxte�'Table Depth _ -------- �'� j <br /> ---------- ,r <br /> i.,. Rock Size ! Z <br /> --- <br /> r w �_ - <br /> , l j G'�----- -----.Foundation /�.�- -t- Prop.?Line +� <br /> �' Distance to nearest: Wel"I =�- -____ - ----•----- <br /> r --------) <br /> R6�11R/ADD1T{QN(Prev. Sanitation Permit* ------------------------------------------- Date --------------•---------- <br /> �, - �' <br /> Septic Tarik {Specify Requirem.erifi) ----------------------------------------------------------------------------------•------------- -- . <br /> l .•�' ----------------------------------- <br /> Disposal Field (Speci„ nRequirements) ------------ ----------------------------------- <br /> x �Y <br /> t- r, <br /> ''r - -------------- <br /> --------------------- <br /> ---------- ` j <br /> - .�' (Draw existing and required addition on reverse side) <br /> s s <br /> i I}hereby certify that 1 have prepared this application and that the.work w N�b__•e done in occordoncexwith San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Sa}ii Joaquin Local Health District. Home owner•�or licen- <br /> sed agents signature certifies the following: <br /> "I certify h the performance of the work for which this permit is issued, :shaH not employ any person in suchmanner <br /> as to be a sub' ct n s mpenaation laws of California." , <br /> Signe <br /> ------By --- ----------i -------- `--------------------- Owner <br /> ;Title ------ - ------ - -------------------- <br /> (If <br /> --------(If other than owner) <br /> FOR-DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY -------717i-_R"-!P --"----------------------- ------------------- <br /> DATE ,► s <br /> BUILDING PERMIT ISSUED --------------------- ----------------------- ---------- <br /> - ------------ -----DATE ----- ----�----- ------�-- -:---------- <br /> �- ---_ <br /> ADDITIONAL COMMENTS __- - ----- --------- <br /> -"-_ <br /> lB • T - <br /> ---------------- <br /> --------- --- ---_ --- - - - _ <br /> -- <br /> �� _ _. -------------------------------- - <br /> - - ate ' " <br /> Fina no - -- - - lfa�-'�--• -- - - --- ---------------• ------D <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F i-I. 9 1268 Rev. 5M __ `'� � co <br />