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FQR OFFICE USE: <br /> APPLICATION FOR SANITATION PEWIT <br /> ------------ ---••---------------------- <br /> (Complete in Triplicate) Permit No. -_-'7- _/Q7„ <br /> - ----- This Permit Expires i Year From Date Issued Date Issued .... . ... ..f4 <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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> r, <br /> JOB ADDRESS/LOCATION 'ri--.-----o-- --------------------CENSUS TRACT ------------- <br /> Owner's Name .- - ----Phone O �= .�_ <br /> 1.--•--------------------�---------- -- --�----�-- ------- 'e'-�f-•� -�'-/;�----- <br /> Address ---------�. f4. ----------------------------------------------------------- -------------,._. City .����.��J�1/--------------------------------------------- <br /> Contractor's <br /> Name -// '. _ [ �---------- 1' ------------- ------- <br /> .License #�,��„���------ Phone <br /> Installation will serve: Residence [4 Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other--- <br /> -Number of of living units------f---- Number of bedrooms -,,'7,---.Garbage Grinder _1V4--- Lot Size <br /> ------- <br /> Water Supply: Public System and name ------ --------------------___- _-------------------------------- -- -- - --- Private- <br /> • - - - - - ----------------- •- <br /> T <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam.❑ <br /> Hardpan ❑ Adobe Fill Material ------------ If yes,type __-----_----___--____--_ _ <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 /> kPACKAGE TREATMENT [ I SEPTIC TANK[ ] Size-------------------------------------------------- Liquid Depth ----------------- <br /> Capacity -------------------- Type -------------------- Material-------------.--------- No. Compartments ----------- <br /> r- Distance to nearest: Well ------------------------------------Foundation ---------------- ---- Prop. Line . ----_ <br /> LEACHING LINE [ ] No. of .Lines ------------------------ Length of each line---------------------------- Total Length :----------------•---•--_--- <br /> 'D' Box------------- Type Filter Material ____________________Depth Filter Material -------------------------------------..._... 0 <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---------...-------:_--- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> i + Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------,........a <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ---------------..__-__-_______--__) <br /> Septic Tank (Specify Requirements) ------ . ----------------------------------------------------------------•-•-•----------------------------..--,,. <br /> Disposal Field (Specify Requirements) ---------41,11/ <br /> =-------------------------------------- --�' i- t` `_.. � _-----------------------------------------_------- <br /> _+ =------------------------- ----------------------- ` <br /> (Draw existing and required addition on reverse side) <br /> w 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 licen- <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 subject to Workman's Compensation laws of California." <br /> Signed ------------------------------------------- � -- --------SC11-11-------- Owner <br /> B �� <br /> 3-, y ------------------------------•---------------- '` �- = Title <br /> (If other than ow r) <br /> w FOR .DEPARTMENT USE ONLY <br /> r APPLICATION ACCEPTED BY -- ------ -- ----- DAT�_ _ <br /> _-0?-6- -_--__------ <br /> NBUILDING PERMIT ISSUED - DAT - <br /> ADDITIONAL COMMENTS ---------------------------------•----- - <br /> ------------------------------------------------------------------- <br /> r ------------------------ --- ----- <br /> ------------------ <br /> --------------------------------- - ---- - -- --------------------------------------------------------------------------------------------------------------q-- <br /> Final Inspectioction by: ------------ -----Date - ---------- <br /> r SAN JOAQUIN LOCAL HeALfH DISTRICT <br /> k—'' E. H. 9 1-'b8 Rev. 5M <br />