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1 <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT y <br /> ........_.........................-�..................... <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires f Year From Date Issued nate Issued <br /> Application is hereby made to the Son 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/LOCATION Wip or - C74- . <br /> -------- ...... .......CENSUS TRACT ...----••-• /.....,._ <br /> Owner's Name ............. . 1...... '3!� - - �✓ C•---- <br /> . ' ... . .rPhone .... <br /> Address .. ...._... ---- . . ----- - -�--.._..._. city ....... <br /> •.F.............. <br /> Contractor's Name ...._..... - -.. :G' -------- -------------------------------License # Phone .............................. <br /> Installation will serve: Residence Apartment House❑ Commercial (]Trailer Court 0 <br /> Motel ❑Other ... . ---------------- �( <br /> Number of living units:.. ...._ Number of bedrooms � b.arbage Grinder Lot Size _... .. c.p.....__..... <br /> Water Supply: Public System and name —...................................__.---....._-..._.....---..._.._---._..---..------....._....._.-------.Private ❑ . <br /> Character of soil to a depth of 3 feet: Sand. Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material .............V yes, type ------ --r—.1.......... <br /> (Plot 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 [ ] SEPTIC TANKj Size <br /> ................. Liquid Depth .......................... <br /> Capacity .. ...... ..-. Type -------------------- Material............. .-..... .No. Compartments <br /> O <br /> Distance to nearest: Well ... ...... ..............__._. _Foundation ...._..__............. Prop. Line ........ ....� <br /> LEACHING LINE No. of Lines Length of,;ach line_..:.1.� -- Total Length ---__ _._.._... <br /> k 'D' Box ...� Type Filter Materiala��_teDepth Filter Material ..........a'2-_IV------------ <br /> __ ..... <br /> Distance to nearest: WeIIt -_.____.._ Foundation _ .,/ _........... Property Line ..-----?..............O_ <br /> i SEEPAGE PIT [ ] Depth . .. ......._ Diameter ...... Number . .. ... Rock Filled Yes [3 No ijj <br /> Water Table Depth -.. •• --------------------------------------Rock Size ........ ---------------------•- �Nt <br /> Distance to nearest: Well ........................................Foundation ........._.. ....-._ Prop. Line .......... <br /> ._........-- <br /> h REPAIR/ADDITION(Prev. Sanitation Permit# ........................ ........ Date ----_-.__.-..-.-... __---------- <br /> Septic <br /> - ._._--Septic Tank (Specify Requirements) ...... -------------------------------- <br /> Disposal Field (Specify Requirements) ---------------------------------------- ----- ---------------•- ---------.--------.........----.................. .... ....... -----• <br /> ......................... ... . -- -------------------------------------------------- --------- .................... ....... <br /> .............. .-- . ._....... ............... ---------------------------------- -------- ----------- ......_.._. <br /> (Dra'w existing and required addition on reverse side) kF <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licem <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 become s . .'Ect to Workman'6 orn esasation laws of California." <br /> Signed _... - <br /> g - - Owner <br />�. By .._. • .................•-----. Title . ... <br /> ......... ....... ...... ..................... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- .. DATE I-2 .. .....-...-- ,L; <br /> BUILDINGPERMIT ISSUED -----------.__.................. •--- . .................. ...........-.. .- DATE . . . . ----------------------- <br /> ADDITIONAL COMMENTS .. .................................... --` <br /> ...................................--------------------------------..._.. -- -.------------------------------------•------�- -----------------L...... ............-- •. •----•. <br /> 1= <br /> Final Inspections by. _ x_ <br /> =-- - - -----• ---- �"'-----•----Date . .d� - a^..__:.._.._. <br /> j <br /> SAK JOAQUIN LOCAL HEALTH DISTRICT { <br /> e �.i �- 7ti • .�n n_-- r�• - - 717ItI U � <br />