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FOR OFFICE USE: <br /> .................... .. .............._..._ _.--..... APPLICATION FOR SANITATION PERMIT �6_ <br /> (Complete in Triplicate) Permit No. ..................... <br /> ............................................... This Pon"t Expires 1 Year From Date Issued Date Issued .............L:.r.. <br /> Application is hereby made to the n 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 /> JOB ADDRESS/LOCATION /f F5"V >t ......... ............. .......CENSUS TRACT ....................... <br /> Owner's Name / mwn' TaX-..tc-� �....... �.:Y ... .^ ........ _)...Phone .. <br /> Address ............:........... ..............................................Ati�''. City..:... . :....`:...:. -- <br /> Contranor's Nome .. .. .........:....... �-`` ` K — :.. ._.......:..... ": :.:_;:. a ��..❑Z. .......;................... <br /> .f. <br /> Ucense � -��ar . Phone <br /> Installation will serve: Residence -• A artmeM House Commercial Trailer Court <br /> Motel❑Other ...`..!P 1-3 .: . .6....... <br /> Number of living units:- .,---..., Number of bedrooms. .'.1.....Gbrbage Grimier .... Lot Size.:....Qre­....... ..... ._._.:-. <br /> " - <br /> Water Supply: Public System and name ........................... ......................*`.. . =..:...... ---------• --- <br /> Private �� <br /> - <br /> Character of soil to a depth of 3 feet: Sand 0 Silt[3 Cloy <br /> ❑' Peat(] Sandy Loam e Clay loom ❑ <br /> Hot pan ❑ Adobe [I Fill Material - _ If yes;type ....:....................... <br /> (Plot plan, showing size of lot,. location .of system. in :relation.to.well s,.buildings, `etc..;mutt be ploced' on reverse side:) _ <br /> f PACKAGE TREATMENT [ � SEPTIC TANK <br /> c r seepyge pit ermined if qEw is gvailgble witHig200 feet,) l <br /> NEW INSTALLATION: �,7/' p <br /> Cd cEPTICTANK Size �1� ✓--p X 5,.. . . Liquid Depth ..: . ... :.... .. 0 <br /> ase ( . ' . . ._ Z 0 <br /> ' al.-..S9!_4 . .... .No. Comportments ' ...... ..........:.. <br /> po 'fy - Type Moteri <br /> Distance to nearest: Well .-" ...IaO .. ...Foundbtion ......A—:......L.. Prop. Line_ ............... Z <br /> LEACHING LINE4/ No. of Lines Len th-of each 16ie .. <br /> i <br /> [ g SP .. . total Length '-•--- . <br /> • : 'D• Box Type FJter Motenal ,� .:Depth- Falter-Ntate'riol /4 ............. -. -....__. <br /> Distonte to'nearest: Well ,:............ <br /> SEEPAGE PIT [ I Depth Diometer Number .i s .*.Rock Filled -Yes ❑ No <br /> Water..Table Depth, ........ ..:.......2....... ...c. .....TRxk Size .................... i. <br /> a ' <br /> Distance to nearest;Well .... _^-- -foundghon freip. Line ................... <br /> R;PAIR/ADDITION(Prev. Sanitation Permit# Dote .. ► _. , <br /> 1 . . <br /> I Septi[ Tank (Specify Requirements) -. ... .. .......... .... . ........................:. <br /> Disposal Field (Specify Requirements) .t.. ` l <br /> .. ..... . ._. . ----- . ..... <br /> . ....... .. .. ......... ...... . .. -- - . . ... ....... <br /> .. ....... .. ...... _........................... : .. ... . . - _. --.-: ....... <br /> '(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 /> 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's'Compensation laws of California." <br /> Signed . _ . .............. ...... ............. .. ...-..: Owner I <br /> By . .. . . ...... ...:. Title ..��+c- <br /> (If other than owner) It <br /> II FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ............. DATE . <br /> ....:....- _......._.._.... DATE .---IL:....�.GS ..�s�s. <br /> BUILDING PERMIT ISSUED ............ l. ... ..........DATE : ..._........._... <br /> ADDITIONALCOMMENTS ................... ................................................:.............:.................................... ...................................... <br /> ................._......---•--------............... . ... .........;-..................._-...-..-..-----=-..... ................. ..------------------------ ........... <br /> FinalInspection by: _._...---- ---. .-.. ............................. .:...................:.........Date ...%.. .....f..yarn.........-..�s-........... <br /> SAN JQAQUIN LOCAL HEALTH, DISTRICT <br /> c u 13 24 , •coo_.. eu! _.. 7/723M <br />