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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br />.............. .,.�.���...---.....-��`.�..Pc.).- �. .... ��(o <br /> - (Complete in Triplicate) Permit No. ':.. <br />...................•................................. ... <br /> .................................. This Permit Expires >I Year From Date Issued Date Issued <br /> Application is hereby made to the Sart 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. 544 and existing Rules and Regulations: <br /> aye � <br /> JOB ADDRESS/LOCATION . �J .../.L.�- / . ... .................. -•...............CENSUS TRACT ..................... ..... <br /> Owner's Name.. _... 7' 3"'_ / ' ................... -------------- -- .... u...Phone_ 3..._.AS.IV.. <br /> Address 1�1?7.�-+.------- = •... ................. --.......:''.City .. :T?3hI<--•-............---....................... <br /> ....--- <br /> Contractor's Name ... :.License# .............. Phone �x�'6 :.O' .4 ... <br /> Installation will serve: Residencepartment House 0 Commercial ❑Trailer Court 0 i <br /> s <br /> Motel ❑Other ............... = - ......... <br /> ...._ <br /> �..' <br /> Number of living units:....- ....., Number of bedrooms 1-1..Gdrbag J. <br /> Grinder ..... ..-... Lot Siz 7 _,...�..�.�........... <br /> Water Supply: Public System and name .-•--:------.•--------------,_.__.__.----- _I�41_ -.-.- -C -- .....Private ❑ <br /> Character of soil to a depth of 3 feet: Sand I-] Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Materfal ......... If yes,lype ............................ �l` <br /> (Plot plan, showing size of lot,.location of system;.in .relation .fio_.wells,.buildings, etc. ;must be placed on reverse :side. <br /> NEW INSTALLATION: (No septic tank or seepage.pit permitted.if public sewer is available rwitKin 200 feet,j. ` <br /> PACKAGE TREATMENT { ] SEPT;iiTC ANK Siae. +�-"�.._.'....... Liquid Dept <br /> Capacity ................ Type: Material------------------ .... ,No. Compartments ..............:....._+_ <br /> Distance to nearest: Well '......:......'.............:.........Foundation .....:...........-:--. Prop. Line-•---•:--...........f <br /> LEACHING LINE No. of Lines ............... 'Length 'of each line.---__-._. ..... ......:... Total Length ............................ <br /> 'D' Box .......... Type Filter'Materldl ....:.: ..::........Depth ;Filter 'Material .................I <br /> -- --- <br /> Distance to nearest: Well ..'.-----.�_-- `___--._ foundation ....�-------------=-- Pro a Line;.........................[ <br /> SEEPAGE PIT ( ] Depth ,-..-:_...- ---_:' Diameter. :.............:.. Number Rock Filled Yes ❑ No ❑ <br /> Water Table Depth. ...................... ........Rock Size <br /> i <br /> Distance to nearest: Well ...........Foundation ' <br /> _.. .. ... . Prop. Line'.......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit _...:_. Date } <br /> Septic Tank (Specify Requirements) -.... ! :.._..':... <br /> 'Disposal Field (S ecify q`iremenYs} c ^ = <br /> ..... ... ......... ._.'3••• -- .. _..,_.........._.._...... _•____.. <br /> .............. .--....... <br /> i <br /> - •--•----------------•---__••••_---••_..........._. i <br /> I <br /> (Draw existing and required addition an reverse side) <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 ewno or licen-! <br /> sed agentsr signature certifies the following: Y <br /> °'l 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 subjec_t_ arkman's'.Compe cation laws California:" t <br /> Signed -.-11.?.cV....:a-t �': .. - ._: .;.. <br /> By ----- - - ------ --------=------------- •----.:----- = 1 ..... : Title .. _ i---•----------- .-.------•- ....... <br /> (If other than owner] <br /> l/.- <br /> FOR bEPARTM NT USE O LY <br /> APPLICATION ACCEPTED BY .. DATE . .............. <br /> BUILDING -PERMIT ISSUED'------ -------':::: ---=------- _:::..:. :.:_ DATE .:. = ......._ -.._ ........... <br /> _I <br /> ADDITION L C MENTS .,. ....:. ............... ... --- -•--....----- ......... .. ' ....:..... , ... .. ... <br /> ....................... . . ............ ... - . .. ..................... .....I. ... ..... ...------....... <br /> Final Inspection by: ---- .-• ......----,- .... : .....:............:............:. .. .- - :_.. Date G.= �= - _ <br /> i <br /> JOAQUIN LOCAL HEALTHDISTRICT <br /> E. H. 1-3 241-'68 Rev. M 7/723m <br />