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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ' <br /> (Complete in Triplicate) <br /> Permit No. <br /> -' W ; This Permit Expires 1 Year From Date Issued Date Issued -7_. v.- <br /> Application is hereby made to the San Joaquin Local Health DistAlt, 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/LOCATION I" T . ."--CENSUS TRACT -----------------•--___--- <br /> Owner's Name ------ <br /> � *-------- --- ;. <br /> ------------Phone <br /> Address .3 --;ti!�u - -- -- :CiYCon1actor's Name `------_-1 -- <br /> - { <br /> f7ti------------License #/0_- /------ Phone G_�sA_7._-Instdilatio�Wil( serve: Residence- Apartment House�E]6mmercial :❑Trailer Court ❑ <br /> Motel ❑Other --- <br /> Number <br /> _-Number of living units:._---"_____- Number of bedroom�__�f_Garbage Grinder ------------ Lot,Size- <br /> Water Supply: Public System and name -----_ Private <br /> ------------------------- <br /> Char cter of soil to a depth of 3 feet: Sand[] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> t Hardpan ❑J'w,Adobe FHI Material _____�-*W yes, type ---------------------------- <br /> (Plat plan, showing size of lot;`;location of system in relation to 'ells buildings, e�c. must be placed on reverse side.) <br /> NE ,INSTALLATION: (No septic,,fank or seepage pit permitted if``pub it c.weT-is'a`v ilable wi#liin 200 fe'et,) \ <br /> PACKAGE TREATMENT [ SEPTIC'TANK'[ J Size`---____ _ __ ---------------- <br /> Capacity --------------""---- Type "------_ --- Material----------------- <br /> - -- No, Compartments <br /> ---•------•------•... <br /> Distance to nearest-:. Well ----------------------------------- --------------- --- Prop. Line --- ------------------ <br /> LEAGHlNG LINE [ ] —N+i"'o`f"tines _ <br /> _-____ _ ..---"--- l=eng th- of each line____________________ <br /> ----- Total Length �----------•---•-•--------•- <br /> Y <br /> D' Box .____ ____--Type Filter,Material _____'____ _ ______Depth Filter Material ---------------- <br /> Distance <br /> __ ___ <br /> Distance to nearest: Well _____________"" ______ Foundation Property Line <br /> ------- -------- <br /> Y -------------- <br /> SEE P�4GE PIT [ ] Depth -------------------- Diameter _- -------- Number -- -------------- ---------- R ck Filled JYes ❑ No i❑ <br /> �. Water Tablet Depth __Vj <br /> Rock Size1. __. <br /> Distance to neares Veell ----------------- ---------------- Foundation --------(A. Prop. Line -----------•---"--_-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ______ ________________ ""- -_ ------ Date <br /> --------._�-------•-------- -- ' <br /> Septic T-dnk(Specify Requirements) ------------------------------------ ----------- <br /> \ a � fit- - <br /> . ------------------ <br /> Dilposal Field (Sp cify Requirements) ----- ---- F \l . 5�.1 t __ <br /> --- =------------ Y <br /> ' k -- ------y.----- 4 <br /> ---------------------------------------------------------------------------------- <br /> �.�'' - Z� X--- --�---------------- --------- ---------------- <br /> ----- ------- <br /> ------------------------------) c <br /> (Draw-existing and required addition on reverse�s'de} �. � <br /> I hereby certify that 1 ave prepared this application and that the work will 6e y ne in accordance with SanJoaquin ` <br /> a <br /> County Ordinances,;State Laws, and Rules and Regulations of the San Joaquin Local„Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in he perfrrma`n e of the work f r which this pe:rrnit is issued, I shall not employ any person. in such manner ! <br /> as to!become�subject to4orkman's Compensation laws of California.” <br /> I <br />-. <br /> Signed --------------- <br /> . :— <br /> -� r .� ------- - -- ----- Owner <br /> � <br /> BY -----------------------------------• Title -------- <br /> f of r han owner) <br /> JFOR�DERARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ____ 3 <br /> - � -- ------------------ DATE "�_1 O <br /> BUILDING PERMIT ISSUED ------ ------------------------ ------- <br /> DATE <br /> ADDITIONAL COMMENTS <br /> ------- ------------ ----------- - - ------------ <br /> i <br /> --------------------------------------------------------------- <br /> ---------------------- <br /> -------------------------------------------------------------------------- - <br /> ---- ------------------------------------------------ <br /> Final Inspection by: - ------ - -- <br /> --- - <br /> - - <br /> ----------------------------- -------- - - -------------.Dat --- --d / <br /> - ------- -- ------------- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />