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FOR OFFICE USE: <br /> C)PLICATION FOR SANITATION PERr) 7,J'~.,z 3 <br /> - Permit No. ................... <br /> (Complete in Triplicatel <br /> ... ..... .............. . .... <br /> .. . .............. .................. .... ...... This Permit Expires i Year From Date Issued <br /> Date Issued . 1-��....._. <br /> t i <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. 544 and existing Rules and Regulations: <br /> 1JOB ADDRESS/LOCATION '�� .�. ��__. . ... �• CENSUS TRACT .......................... <br /> Owners Name ------- --- --------- -- -- - --- hone <br /> Address (G,q. �_ .. . �.,1 e� .'._ ., .... - City . .. C �.�_G—a <br /> TL: <br /> 3 <br /> Contractor's Name . cense Phone <br /> Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court Cl <br /> RMotel ❑ Other <br /> Number of living units:_ il. . . . Number of bedrooms .4�.-.-Garbage Grinder Lot Size .... E_lr- .[='. <br /> tWater Supply: Public System and name . ....----....--- ----- ----------------------- -------...Private �� <br /> ,,Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam E Clay Loam 0 <br /> Hardpan [[ Adobe ❑ Fill Material . __ If yes, type <br /> 2f.{Plot plan, showing size of lot, location ofsystemin relation to wells, buildings, etc. must be placed on reverse side.l. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted��iif,public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK fe Size.1%_!x-_ I_! X_.. . Liquid Depth <br /> Capacity 4 c -"4J Type 4L. t_f Material. '- { ^ .... No. Compartments _,.:21_-_--_--._-- <br /> Distance to nearest: Well 1� �..f` ?- ��'-... . Foundation .1.0'.. k ......_ Prop. Line _ Sr ......_..... <br /> LEACHING LINE [►l/ No. of Lines 3 . Length of each line LI-6, ` . ... Total Length — <br /> ' 'D' Box Type Filter Material Depth Filter Material <br /> i ! <br /> Distance.to nearest: - <br /> �SEEPAGE PIT [A,- Depth Diameter _� .Y._,- Number .... Rock Filled Yes E!T'-'No i❑ <br /> Depth Water Table r <br /> ' P - � �' --- -- .. Rack Size <br /> Distance to nearest: Well �.. -[.__. __-.__..._._..Foundation ....Oz:'.Jc ... Prop. Line .....: �....... <br /> EPAIR/ADDITION{Prey. Sanitation Permit# -- ----- ............. Date --__---.-.--_-----.------.--_-._--1 <br /> Septic Tank (Specify Requirementsl ---- - --I........ ...................... .......... ..... ..... ... .............. <br /> Disposal Field (Specify Requirements) .- - -- ...... . . . . .... .. ... ........ . . . - ------ ..... <br /> - .-_­. ­.............. . ........ ....... .... . ..... .....-° ........... . . ......................... <br /> ...... <br /> ' (Draw existing and required addition on reverse side) <br /> Fhereby 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 /> f sed agents signature certifies the following: <br /> II certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> i f 'as to become subject to Workman's Compensation laws of California." <br /> Signed . . _ Owner <br /> r <br /> 'Title , -C <br /> i (If other than owner) <br /> FOR EPARTMENT USE ONLY <br /> 4PPLICATION ACCEPTED BY DATE . F <br /> ,. <br /> _3UILD1NG PERMIT ISSUED DATE . <br /> ADDITIONAL COMMENTS .. . .... .................. . <br /> .... .. ..... d.. - ------ .... - - .... .... ... .. ........... <br /> 4 {.......,- .... _ -- -- - ... .. ---- ........ <br /> . <br /> *�------- - ...... - - ..;-. -- -. .. ....... .... ...... . .- ......... ' <br /> Final Inspection by: . . _..- _----------- <br /> ------- <br /> -- -- - . . .._.. - - .. ........ ..........� --- - - -... . .Date ���:._ _. .- <br /> f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F N 13 241_'!,G De., 4AA -71Tg `2 u <br />