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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ................ ............................... <br /> .... Permit Na. ..................... <br /> Doti Issued .1... .......... <br /> (Complete In Trip;Icate) <br /> ...........................•--. .............. <br /> ...................... ........ .............. This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Son 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 /> IS G 0'-A <br /> JOB ADDRESS/LqCATION .................I..............I..............-........... .......... .....................CENSUS TRACT ....__.................. <br /> Owner's Name qq. . ...... J.............................................................I......... <br /> .....phone ..........................-....... <br /> all <br /> Address ........ .....................•----•..------.........._............ city . ...... . ........... -------------------- <br /> Contractor's Name ........... ...... <br /> ...... .....___.................. .................. .......License # ..... <br /> .... Phone ...........-••••-••••-•-•••-•- <br /> I <br /> Installation will serve: Residence Apartment House a Commercial OTraller 'Court 0 <br /> Motel 0 Other.............. ..............r................ <br /> Number of living units------------- Number of bedrooms ............Garbage Grinder .......... Lot Size ......_---:-•____......__.::.___---._....... <br /> Water Supply. Public System and name __�...................................­­ ....Private 0 <br /> Character of soil to a depth of 3 feet. Sand Silt Clayo Peato Sandy Loam O Clay loam o <br /> Hardpan 0 Adobe 0 FIII'M6terial .............. If vast type ............... ............. <br /> (Plot plan, showing size of lot, 14cation 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 /> PACKAGE TREATMENT I I SEPTIC TANK( 3 Size............:...................•- ............ Liquid Depth ........................... <br /> Capacity ...... -------._.. Type .................... Material....................... No. Compartments ................. <br /> Distance.to nearest:. Well ....................................Foundation ................ Prop. Line ................. <br /> LEACHING LINE, No. of Lines ........................ Length of each line-_____.... Total Length ........................ <br /> V Box ............. Type Filter Material .....................Depth -Filter Material :........................................... A <br /> Distance to nearest. Well ____..........4__... foundation .....L................... Property Line ........................ <br /> SEEPAGE PIT Depth ..... ------_--- Diameter ................ Number '........... ............... Rock Filled Yes 0 No 0 <br /> Water Table Depth - ................Rock Size ... ................... ....... <br /> o <br /> Distance to nearest: Well ----------------------------------------Foundation _................. Prop. Line ....................... <br /> REPAIR/ADDITION(Prev. Sanitation,Permit# ....................... _-_-_-_-- Date ..........................I <br /> Septic Tank (Specify Requirements[ <br /> ............. ..........................:............................................................................ .................... <br /> Disposal <br /> .­..-.-.--.-.-.- --------------F---i- <br /> --Id-- <br /> J-S-&-p--e-_"clfy Require nijants) ......-.....-.-.-.-.-.-.-.- <br /> ... -......-......-..............-px <br /> .�.......-....._...a.......4......j.... <br /> ....j....... <br /> ............�......'...P...�.......... <br /> _._.... ... V..Y...!.L..k... <br /> .4 <br /> ...... <br /> -------- - - .. ......t-----.. ...........................JDraw existing and re 3r4G�4on on reverse side) <br /> .. <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 Son Joaquin Local HeiltIt,District. Home owner or. 111ceni- <br /> sod agents signature certifies the following: <br /> lowing- <br /> "I certify that in the performance of the work for which this permit Is Issued, I shall not employ an.y person in such manner <br /> as to become subject to Workman's Compensation -laws of California." <br /> Signed,i3y� <br /> -- ---- ----- --- ............................ Owner <br /> ............ <br /> - ----------- <br /> --------- ---7_3---------- - Title ................. -------------------------------- <br /> _n, <br /> 11 other than ow ew�� <br /> % FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYI)41\�. ... <br /> -------------------- ----------- ............... . DATE -------V- ----------------- <br /> BUILDINGPERMIT ISSUED ......................*-----------­------ ---------------------------------------- ----DATE ----------------------------------- <br /> ADDITIONAL COMMENTS -------------------------------------------- <br /> ............ I------------------------ ------------------------------------------- ------ ----------- .............................................................•--......-.._.._._._... 7 ....... <br /> ----------- ---------------------------­-- - ------ ------------ ------*-----------------------------*-------------------------------------------- -----------------------------------*---------------- <br /> -­----------------------- -----------------L----------I...... ------------------------------ 3.6..................... <br /> . <br /> Final Inspectio ......... . ------- ••..:..__...--­-------I---------- --------------Date ­"-1- <br /> %- � <br /> -------I......................... <br /> EH 13 24 1-6 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />