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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................................... .......... .� Permit No. 7y- 9� / <br /> (Complete In Triplicate) <br /> ,�.._ �--. �. _ _ _ ..,,- . <br /> -------------------•--......--.-.._._.......---•----__-.. . This Permit Expires Z Year From Date Issued .. . <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrt ct 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 <br /> ./.. ......................--.-........................CENSUS TRACT .................... <br /> Owner's Nome ...__(�_ ... i � '�e'' ------------•-•.................................................................Phone .................................... <br /> Address ._. <br /> ?� :... _..: ..... city ' _ <br /> Contractor's Nome `` ._....*.�.......................License # `Z?Y.. Phone <br /> Installation will serve: ResidenceApartment-House fl:Commercial OTrailer Court C] <br /> Motel 0 other ... ........... ............ <br /> Number of living units:...`_.__ Number of bedrooms ---Z--___.Garbage Grinder <br /> 0! elot$Ize .&P,f;..-./.. e................. <br /> Water Supply: Public System and name ...6,01j _ ......Private Q <br /> -go—n4— <br /> ............. <br /> Character of sail to a depth of 3 feet- 4 Sand Silt C_lo Peat Sand"to m f Cla Loam <br />. p ti,r� a y o� a � y fl y ❑ <br /> Hardpan[] Adobe Fill Material ............ If yes,type ............... �L <br /> (Plot plan, showing size of lot, location of system in relation to wells, bulldi gs,,etc:-mast'6e .placed an reverse side.` <br /> V <br /> NEW INSTALLATION: (No septic tank or seepage pit ,permitted if public sewer is available within 200 feet,[. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] <br />. . . .., �.. Size.......-....------------------------------------ liquid`Depth ......-................. <br /> . <br /> Capacity _-----------_--- Type ---------_-------- Material..................... No. Compartments <br /> Distance to. nearest:Well -- -.Foundation .r..:_.. Prop. Line <br /> -------—• .....- ................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line...-------------------.-..... Total Length .....---.................... <br /> V Sox ..---------- Type Filter Material ....................Depth Fitter Material ...... ................................ 1_ <br /> Distance to nearest: Well ........................ Foundation ....................... <br /> Property Line <br /> SEEPAGE PIT ( I Depth __----_---------_- Diameter ----------=----- Number ................__..__....... Rock Filled Yes 0 No <br /> } <br /> Water Table Depth ------------- --------------- ...............Rock Size'_'. � <br /> Distance to nearest: Well <br /> _._Foundation ...:................ Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -•------.__ •------------------------ ..... Date ----._............................ <br /> 1 <br /> Septic Tank lSpecifyfiRequirements) -•---J= ..------------------ - ------------------------ <br /> ------•-- ....._......... - <br /> Disposal Field (Specify Requirements) --• <br /> - ..�.,. ----•------ ..— - - � ....................... , <br /> •------------------------------ <br /> (Draw existing and required addition on reverse sidel J <br /> I hereby certify that I have prepared this application and that the work will be done In accordanie with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:Dlstrlct. Home owner or liken- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of :the work for which this permit is issu6d,' I! shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." E <br /> J <br /> Signed -----•-------------- -••----------- Owner { <br /> By ----- -� Title <br /> ...--- _ --.._.. <br /> (if o r t an owner) <br /> I <br /> 1`0160ARTMENT WE ONLY <br /> APPLICATION ACCEPTED BY _. PATE ../.p. 77-'7.. en. .,. -=:---: I <br /> BUILDING PERMIT ISSUED -- -----------...............•------_. ..........................-------DATE ...._ -------------- -- ... _.._ . <br /> _-.-•----- ---------- ---- <br /> ADDITIONAL COMMENTS _ <br /> ------- -----------• ---•--------------- .._..... --• •--------•--•.................-•.... t <br /> ----- ----------------- ---------•-- ._...---- <br /> ------------ <br /> Final Ins codon by- `--. /.� - ZZ� �/ <br /> ------- .. _. .-- ...----• -------i:--•...... ...................Date J_._. <br /> ---------- <br /> SAN 13 .21a -613v. SAN JOAQ.IJIN LOCAL EALTH D#SfiRICT 8�7�t 3M <br /> y <br />