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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............................................. .. Permit No. <br /> 1£omplefe in Triplicatol y........... <br /> ...........•............................................. This Permit Expires 1 Year From Date Issued <br /> Date Issued . ...:,e.:. .... ` <br /> 'Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> described. This application is made in compliance ith County Ordinance No. <br /> 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCAT#ON _ �.ly.._Z .. ...� v., l..:._...__._�..f'C°, �a� <br /> T - •....................CENSUS TRACT ...QA6.............. <br /> Owner's Nam i 6972We- --._ -tet lrf�j/.` ��- <br /> -.. - . �.................................................._...._.............Phare ... .�2-?-�---- <br /> Address ....... i txi ..... } .._.__... - City _................. ....... .................. ------ <br /> Contractor's Name ----------------------------=---------------• -----...._._.. .------------...........License 0 ••.... ........... Phone .....:...--- •-•-•- 4 <br /> Installation will serve: 'ResidenceXApartment.House❑ Commercial❑Trailer Court 0 <br /> Motel ❑Other_'. r <br /> Number of living units:_--!....... Number of bedrooms __,J....Garbage Grinder Lot Size l ..XR.O.D......:...., j <br /> Water Supply: Public System and name ._...private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay ❑ Peat❑ Sandy Loam ❑._-.'-Clay.Loam ❑ <br /> Hardpan Adobe❑ Fill Mater€al ....... i 'If yes,type ............... ........ <br /> (Plot plan, showing size of lot, location of system in nelatlon to wells, buildings, etc.' must be placed on 'reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if pub) c sewer i avd able' €thin 200 feet,) <br /> PACKAGE TREATMENT [ ] . SEPTIC TANK I ]5k),V/4 Sixe.- .:_ X Liquid Depth ................. <br /> I Capacity ------ Type _ --- Material.. No. Compartments <br /> ....--•--• .......... <br /> Distance to nearest: Well .................+.._.............•Foundation 4..................... Prop. Line ....................... <br /> LEACHING LINE [ j No. of Lines ....../--------------- Length of each line.._._.�7� ..___`..-----. Tota! Length _..._ .:.. <br /> ".:• 'D' Box ............. Type Filter Material ....................Depth Filter Material _.._.._............. .................. <br /> • c <br /> "i k�► Distance to nearest: Well ........................ Foundation _/�7�..._.__.._. Prgperty Line ...,Sf.............V <br /> . ' ( ! Depth .-- _.._...__- ........... •--- <br /> Number _-----_--_ - ............. Rock Filled Yes V No ❑ ' <br /> r f� 1- Water Table Depth ' _... f <br /> y x '! Rock Size . <br /> Distance to nearest: Well....../0Tf- <br /> _ ----- - --------......Foundation ._fQ .__ -, Prop.-tine ... .......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......................... ------ Date ..................................I <br /> Septa Tank (Specify Requirements) ................ <br /> ----.- •-•----...._ <br /> ------------------•-----...-----------....................--------------.....-..••---•--••-............. <br /> Disposal Field (Specify Requirements) ________________ ____ F <br /> ---------------------------- r. <br /> r (Draw existing and required addition on 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 /> Courby-Ordinances, State Laws; and Ru#es and Regulations of the San JaaquinJocal Health,,Districi. Home owner or licen. <br /> sed agents signatZire certifies the'fallowing: <br /> "I certify that in the performance of the work for which this permit is Issued, l shalt not employ any person in such manner <br /> as to beco � subject to Workman's Compensation laws of California. <br /> Signed --•--- -•----------- -----------••--•--------------------- -------------------------- Owner k <br /> By :.. ;--••-------..k ------------------------- --• xitle -------- --- . -- <br /> A lif outer than owner) <br /> ­17 F9P DEPAJtTMENT USE ONLY <br /> APPLICATION.ACCEPTED BY _:---- -•- -.-.:. DATE . .ri <br /> BUILDING PERMIT ISSUE <br /> ADDITIONAL COMMENTS :- - / ...... -.- - ----------- --------------DATE <br /> ----------- - ----------------------------------------------------------------------•---.....---------------------------------- •----- -...------------.------..-..-.....---------- <br /> --------------------=• •---------------••--- ......- ------- --------------------- ---------------------------------------------------.-.-........ -- -------------------­ <br /> ........•----------------------- - -- --- . <br />` l=ira) !ns'pection by: Date7 -.�� <br /> Iii 13 2It 1-613 -- v. 5M SAN JOAQUIN LOCAs. HEALTH DISTRICT 874 -3M <br />