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FOR OFFICE USE:
<br /> ..,..'...:t,- .`:......:......r......r....l~ APPLICATION FOR SANITATION PERMIT
<br /> iCarnplete in Triplicate) Permit No. .....................
<br /> .,...'.. ......... ... .................r
<br /> . ...... This Permit Expires? Year From clot*Issued Date Issued,, .:.. ....,!..
<br /> Application is hereby made to the San Joaquin local Health District for a permit to construct and Install the work heroin
<br /> described, This application is made in compliance with County Ordinance No, 549 and existing Rules and Reguiotionsx
<br /> JOB ADDRESS OCA7 ,r�
<br /> IL .�j.'.�>�.�.....4�+!���.�..�. .. ....,�..,..,..,..r......................CENSUS TRACT
<br /> Ctwner`s Name .fir 04' 7. �..................................... .://..............Phone
<br /> %dr
<br /> Address _ .i�'w✓......... ;,k,...r.._...,.r..........rr.r.. City jrr /...............................
<br /> ...._ ..
<br /> Contractor's Nome _..._..yr' r s{,r• ''�� > �i...'.`...'_...... _....,license# sr7 ..f °.rte-r'i� Phana�'/I .r.
<br /> installation will serve: Residence Aportment House l3 Commercial OTroller Court 0
<br /> Motel 0 Other '
<br /> Number of living units:..._... Number of bedroom' i .,. Size eU ....
<br /> 1�.�:.r«,,.�ge Grinder�� irrt s.�� ...... .
<br /> Water Supply: Public System and name ......I............ .r_r.... .._.._.r............._....... ...................................... �•
<br /> Character of sail to a depth of 3 feet: Sand Silt[3 Clay 0 Peat Q 5r�ndy Loam i rCioty Loam D �1
<br /> Hardpan 0 Adobe Od Fill M6terial............if yes,type........................... �A
<br /> {Plot pian, showing size of lot, location of system in rotation to wells, buildings, etc, must be placed`on-revefte sldlell_�
<br /> NEIN INSTALLATION: INo septic tank or seepage pit permitted if public sewer Is avoliablithin'2i0 feet,) .
<br /> ..r.r.� e w �„w 31
<br /> PACKAGE TREATMENT ( 3 SEPTIC TANK{ 3 _ ✓ ”`
<br /> sixe.............................................:....liquid £iepth .,.,............. ... _
<br /> Capacity .................... Type ' ............... Material...._... �:' .JNo,�Comparrn-wents ......................
<br /> Distance,to nearest: Well .._ ». ........ foul...r.................. Prop, Line............
<br /> LEACHING LINE [ j No. of lines . — . :.% -Ltlrt0h of�eoch ..........._.............. T h __.......
<br /> . W ata! lettgt
<br /> 'D' Box ...... ..... Type Fitter Mote3 ia1 f Depth filter Material ..........................................
<br /> Distance to nearest z Well`........_:.....,..., Tvurii atirm
<br /> oar~ltr
<br /> SEEPAGE PIT j j Depth Diameter .....A:...,_.:. Number . .`. `. ,,.,,.,r ilex is filled Yes 0 N >~j
<br /> Water Table De o
<br /> Depth ...>....r,.r,r...............Roek Size! .................................
<br /> Distance to nearest: Well .........................,....,........foundation .................... Prop. Lina ...................
<br /> ...
<br /> REPAIR/ADDITION(Prev. Sanitation Permit#_. ........................r......... Date ..
<br /> ...)
<br /> Septic Tank'(Specify Requirements):............
<br /> ... ....._ .. ...:.........r..J..'
<br /> Disposal Field (Specify Requirements)
<br /> .� .,,..,
<br /> .......... ..�`` . '- ................................. .......>._...,_:
<br /> _................ .__......r...,..................
<br /> i `(Draw existing and required addition on reverse side)
<br /> I hereby certify that l have prepared this oppllr094n and that the wane will he dons in attordowwo with San J"quln
<br /> County Ordinances, 'State Lows, Band Rules and R*411ilations of the San Joaquin L*tal Health,District.Mento owner ar flow
<br /> sod agents signaturo certifies the followings
<br /> "I certify that in the performante'of the work for which this pemlt is Issued, I shall nor employ any person In such mannet
<br /> as to become subject to Workman's Compensation laws of California.*,
<br /> Signed ...... Owner
<br /> By
<br /> .........._.................., Yol
<br /> oyher than ownerl G� yy %'j'�✓ ''.
<br /> FOR DEPARTMENT USE ONLY
<br /> APPLICATION ACCEPTED BY.. .. ,r
<br /> .. DATE ....L�:'-��.:.r�..............
<br /> BUILDING PERMIT ISSUED ..........................................:. DATE ...,.,..,; :.,..,
<br /> ADDITIONAL COMMENTS ...................... ................... .
<br /> .....
<br /> ....� ....... ....... ............... ,. .......................................... ..r
<br /> ...:.......,........ ..:.....................,.....,................_...........................
<br /> ..........._ rr.rlc a.... ....„..... .......�.*r.#'IYr". +r,.„rr•_,.,• >,,.•...-r,...sr,..............vr
<br /> I,eat Inspection b ;�. r.. ..,,.; ;1 �..._ >,.,. � ........ ..............
<br /> l322� ~:l £i 8 n ...........................> .....................................Date 9 `"�' :,✓ '.. ..............
<br /> .EH • SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M
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