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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />........... .......... Permit <br /> (Complete in Triplicate) <br /> .................�_.4. ... <br /> This Permit Expires 1 Year From Date Issued Date Issued/A.-./k. - <br /> Application is hereby made to the San Joaquin Local Health District for a permit for construct and install the work herein <br /> described. This application is made in-torc►plionce th.County Or nance No. 549 and existing Rules and Regulations: <br /> ' ._...CENSUS TRACT .:....:.......... ..}. <br /> ,106 ADDRESS/LOCA TiO ..:.�/...5.._... _ ..t�.�. -�- - . .......... , Q <br /> Owner's Norrie .Phone . M . Cl. <br /> Address .. . .... .. <br /> Contractor's Name, %=.:__'. :...: 'Phone'E?� <br /> Installation will serve: Residence 94artrnent House a[—C- omniercidl ❑Trailer Court; ; <br /> Motel ❑Other ... .... . ......... <br /> Number of living :unit's:.,_I.—.—Numbeir. : -of.bedrooms_.. I ..... drbage G i r_ 5iie. <br /> -,- : �. _ : <br /> Water Supply: Public System and name _...-:---.........:......:.... ❑ . . <br /> . -, .l__..•.:._...� .Private � N <br /> Character of soil to a depth of 3 feet: Sand❑, Silt❑ Clay ❑ Pe t❑ Sandy Loam' Clay Loam:❑ <br /> ' Hardpan ❑ Adobe ❑ Fill Material ._ I yes,type ........... <br /> {plot plan, showing stxe nf.lof,,location of systerrt �n.relation to uvells, buildings, ett..;must..be. ,p.lated on ;reverse side <br /> ' t w r i available within 200 feet : <br /> NEW INSTALLATION: (Ne septic tank ar seepage;pit permitted if public se e , s ,1; <br /> PACKAGE TREATMENT C SEPTIC TANK ] Sise ____ . <br /> Liquid Depth }. <br /> i Capacity ....,Type .. ,. Material No Compartments ..:..:._._ _ <br /> .:_. <br /> i Distance to nearest: Well ; a Foundation *_. . Plop. Line{ ... <br /> LEACHING LINE C f- •. ' ... . . ' length of?each line.. o ? engeh ._. .. i <br /> No.' of Lines Total', .� ; <br /> " 'D` 'Box _: 'Type Filter''Material) :'De'pth' Fitor 'Material .............:-•-- .. _ =4 <br /> Qistante-td- Well . ...•_' _i.#._..:. : Foundation {:.....�:.:.:_s:.___ Prtiperty Line t ......... <br /> i <br /> '...... .:.Numkier �... Filled Yes ❑' No <br /> SiEPAGE PIT j l Depth ;.:_.-: ......:- Diameter <br /> Rock d <br /> Water :Table. Depth`: .r....... .. ... .Rock Size ...... , ... <br /> � . . �- .. .-•- � op. line' •- ...... ....i <br /> � . Distance to nearest Well ..Foundation Pr . <br /> j <br /> REPAIR/ADDITION{Pre:. Sanitafiion; <br /> Per: s# ••.........:..... ..... ___._._....: <br /> Date ) <br /> !Septic Tank (Specify'Requirements --------- , ......... -•---• ...... .............' .. . <br /> }Qisp sal lel (S t�fy 'Re uiremen s) . <br /> �-�-- <br /> --- ------- -- .... <br /> (/ {Draw existing and required oddition on reverse sidel '' <br /> I hereby certify that I 'have prepared this appliication and that:the< work will be e�one in accordance iwith;San Joaquin <br /> County Ordinances, State'laws; antl Rules 'a nit'Regulatwn: of the San Joaqu- Local Health District." lomg owtier"or licei►-$ <br /> reit agents,signature ce"rtifies.the fallowing ;...- f - .... <br /> "iscertify that in the performance of the wo!k for which this'permit is issued, I shall not ernploy any Iiarson in such manner <br /> i as to become subj.; to Wor�irna ':'Comp nsation lawy of California: <br /> 1 <br /> Signed'. .v .t ....... <br /> iter I. <br /> By' .........:....... ............_.. <br /> (if other thou owner) t <br /> FOR DE RT ENT US ONLY I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> t BUILDING •PERMIT 'ISSUED:. ... ..::.: :.. : .:.: <br /> A DITi NAL COMMENTS . _ •• - . <br /> �. ` „ .. DA ` <br /> • : :: _ . •• :: 7 <br /> ::__._:_ <br /> ..._.._ _____ <br /> .__. :{..... _ .................. .:... <br /> Final inspection.by. - -�::.., r <br /> .. _ .. <br /> _ ....:,...Date � .. <br /> N JbAQUIW LOCAL�HEALT4 DISTRICT � <br /> ..-1, A•a R n•S+n...a.rv.uiwr. ...�.i.::b•a..rvu..S.....:....wr.•.r-xn�.-w.p <br /> i .._M .. 7/723 ,K <br /> t E_ w.1.3 24 1--68 Rev. 5M <br />